Courses How to Expand Your Practice With Telepsychiatry Director: Jay H. Shore, M.D., M.P.H. Thursday, October 19, 2017 Faculty: Peter M. Yellowlees, M.D., Robert Lee Caudill, M.D., Steven Chan, M.D., M.B.A. Buprenorphine and Office-Based Treatment of Opioid Use Disorder EDUCATIONAL OBJECTIVE: Director: John A. Renner, M.D. At the conclusion of this session, the participant Faculty: Petros Levounis, M.D., M.A., Andrew J. should be able to: 1) Understand how to select an Saxon, M.D. appropriate model of telepsychiatry care and develop an integration plan for to match EDUCATIONAL OBJECTIVE: telepsychiatry model into a specific practice setting; At the conclusion of this session, the participant 2) Understand methods for adapting telepsychiatry should be able to: 1) Discuss the rationale and need into various health care environments and solutions for medication-assisted treatment (MAT) of opioid and best methods of successful integration of use disorder; 2) Apply the pharmacological telepsychiatry into psychiatric practice; and 3) characteristics of opioids in clinical practice; 3) Comprehend how national standards and guidelines Describe buprenorphine protocols for all phases of for telepsychiatry, clinical workflows, e-treatment treatment and for optimal patient/treatment team coordination, and APPS can be best adopted matching; 4) Describe the legislative and regulatory for the creation of telepsychiatric practice. requirements of office-based opioid pharmacotherapy; and 5) Discuss treatment issues SUMMARY: and management of opioid use disorder in Telepsychiatry, in the form of live interactive adolescents, pregnant women, and patients with videoconferencing, has reached maturity as a field acute and/or chronic pain. and is being adapted in a wide variety of health care settings. It is demonstrating its ability to increase SUMMARY: access to care as well as shift models of health care This course will describe the resources needed to set delivery. There are now many demonstrated up office-based treatment with buprenorphine for successful models of providing telepsychiatric care. patients with opioid use disorder (OUD) and review Identifying the most appropriate model of 1) DSM-5 criteria for opioid use disorder and the telepsychiatry for subsequent adoption into an commonly accepted criteria for patients appropriate individual psychiatric practice or organization is for office-based treatment of OUD; 2) confidentiality critical for building scalable and sustainable services. rules related to treatment of substance use Successfully integration of telepsychiatry into an disorders; 3) Drug Enforcement Administration individual psychiatric practice or healthcare requirements for recordkeeping; 4) billing and organization requires careful planning, development, common office procedures; 5) the epidemiology, and implementation. There are a core sets of issues symptoms, and current treatment of anxiety, and challenges around clinical standards, workflow common depressive disorders, and ADHD and how and education that need to be address for successful to distinguish independent disorders from integration to occur. The course will be taught by substance-induced psychiatric disorders; and 6) psychiatric national experts in telepsychiatry in common clinical events associated with addictive highly interactive demonstration session with the behavior. Special treatment populations, including audience. The course instructors will take the adolescents, pregnant addicts, and geriatric, HIV- audience through the integration of telepsychiatry positive, and chronic pain patients will be addressed, into two hypothetical practice settings; 1) Home- and small-group case discussions will be used to based private psychiatry and 2) Integrated Care reinforce learning. Telepsychiatry service covering the salient administrative and clinical issues in the creation of Friday, October 20, 2017 such a practice. Administrative topics to be addressed will include needs assessment and planning, model selection, legal and regulatory and Mental Health" workshop will feature issues, resourcing and reimbursement and clinical presentations on: (1) an overview of the complex needs. Live interactive mock video conferencing connections between marijuana and mental health; sessions will highlight important clinical issues (2) medical marijuana, including pharmaceutical and including safety management, clinical process dispensary formulations, efficacy in treating physical adaptation to videoconferencing, managing hybrid and mental health conditions, dosing, interactions doctor-patient relationships and virtual team work. and monitoring; (3) synthetic cannabinoids, including physiological, physical and psychiatric effects; (4) Marijuana and Mental Health psychiatric complications of cannabis use, including Director: Dan Nguyen, M.D. impact on anxiety and mood disorders; (5) marijuana Faculty: Thida Thant, M.D., Marc Manseau, M.D., and psychosis; (6) short- and long-term effects of M.P.H., Taylor Black, M.D., Erica Rapp, M.D., Jesse cannabis use in adolescents; (7) legislation and policy Darrell Hinckley, M.D., Ph.D., Charles Luther, M.D. related to medical marijuana; and (8) the treatment of cannabis use disorder, including EDUCATIONAL OBJECTIVE: psychotherapeutic and pharmacological At the conclusion of this session, the participant interventions. should be able to: 1) Identify various dispensary and pharmaceutical formulations of medical marijuana Saturday, October 21, 2017 as well as synthetic cannabinoids; 2) Describe how cannabis use impacts psychiatric illnesses including 2017 Psychiatry Review and Clinical Synthesis mood disorders, anxiety and psychosis; 3) Recognize Directors: Philip R. Muskin, M.D., M.A., Tristan the short and long term effects of cannabis use in Gorrindo, M.D. adolescents; 4) Understand differences between Faculty: Ilse Wiechers, M.D., M.H.S., M.P.P., Ashley highlighted medical marijuana programs as well as Weiss, D.O., M.P.H., John W. Barnhill, M.D. the current state and implications of current legislation; and 5) Know treatments for acute EDUCATIONAL OBJECTIVE: cannabis intoxication and cannabis use disorder. At the conclusion of this session, the participant should be able to: 1) Identify gaps in knowledge in SUMMARY: psychiatry and neurology through self-assessment; Marijuana use is a controversial and provocative 2) List key diagnostic and treatment strategies for topic across the United States. Opinions about major disorders in psychiatry; 3) Create individual marijuana can range from it being a harmless natural learning plans for addressing knowledge gaps; and 4) plant with medicinal value while others view it as a Convey a working knowledge of the various topical substance of abuse with overstated benefits and areas likely to be encountered during lifelong understated risks. Despite the classification of learning activities. marijuana on a federal level, marijuana use is becoming legalized by states across the U.S. and SUMMARY: highlights the ambivalence about marijuana in our Using a "flipped classroom" design, participants will society. Research currently suggests increased engage in a multi-week self-study exercise designed teenage and adult use of marijuana in states with to increase knowledge and critical reasoning of legalized medical marijuana with noted harmful essential psychiatric and neurology topics. On effects for adolescents and those with psychotic August 15th, 2017, registered participants for this spectrum disorders. With the increasing prevalence course will receive by mail three textbooks. The first and availability of marijuana products, medical book, Study Guide for the Psychiatry Board providers will need to become more informed and Examination, consists of several hundred self-study well versed about marijuana beyond the scope of multiple-choice questions (MCQ) including answers addiction. This workshop will familiarize attendees and explanations. The second book is a curated with this new culture of legalized medical marijuana compendium of review articles from FOCUS: The and its implications for psychiatry. This "Marijuana Journal of Lifelong Learning, which have been compiled to summarize current diagnostic and disorders can have substantial impact on the treatment approaches for major disorders in affected children and their families, as well as across psychiatry. The third text is Approach to the systems including educational, medical, adult Psychiatric Patient, a case-based exploration of workforce, and juvenile justice. While there is psychiatric topics. Course participants are increasing evidence of the validity of many encouraged to use these materials to review major psychiatric disorders in children down to the topics in psychiatry prior to attending IPS: The preschool age, developmental differences exist, both Mental Health Services Conference. During the live while comparing children and adults, as well as portion of this course, participants will work in small within the pediatric population. Similarly, there are groups and with expert faculty in general psychiatry, important developmental differences in geriatric psychiatry, child psychiatry, and consult- psychopharmacological treatment approaches and liaison psychiatry to complete a series of case-based in the incidence of adverse effects. This course will vignettes that have been designed to illustrate high- provide an overview of recommended treatment yield and key learning points for major disorders in approaches for non-child and adolescent psychiatry. This eight-hour clinical synthesis session psychiatrists. Specifically, the presentation will is designed to help learners integrate and apply review the developmental differences in child knowledge through clinical vignettes and to psychopathology compared to adult reinforce key principles in psychiatry. psychopathology with particular attention to attention deficit hyperactivity disorder, disruptive Sunday, October 22, 2017 behavior disorders, anxiety disorders, depression, disruptive mood dysregulation disorder, and bipolar Psychopharmacology in Child Psychiatry: A Clinical disorder. The course will review first and second line Course treatment approaches, the relative strength of the Director: Mary Margaret Gleason, M.D. evidence for these approaches with attention to the Faculty: Vininder Khunkhun, M.D., Myo Thwin Myint, evidence supporting psychotherapeutic approaches, M.D. and clinical strategies for monitoring treatment effects and adverse effects. EDUCATIONAL OBJECTIVE: At the conclusion of this session, the participant Forums should be able to: 1) Be able to describe the developmentally specific features of common Thursday, October 19, 2017 psychiatric disorders in children and adolescents; 2) Be able to identify first and second line treatments Current Mental Health Programs in the Military for common child psychiatry disorders; 3) Be familiar Chairs: Elspeth Cameron Ritchie, M.D., M.P.H., with the strength of the literature supporting Christopher H. Warner psychopharmacologic and non-pharmacologic Presenters: Dennis Sarmiento, M.D., Philip M. Yam, treatments for youth; and 4) Be able to name non- M.D. proprietary measures to track treatment effects in children and adolescents. EDUCATIONAL OBJECTIVE: At the conclusion of this session, the participant SUMMARY: should be able to: 1) Understand psychological Over 10% of children and adolescents experience a reactions to serving in the military in the last 16 psychiatric disorder in a given year. There are only years of war; 2) Know about military programs to 8,300 child and adolescent psychiatrists in the alleviate and treat psychological reactions to country to serve the needs of an estimated 15 combat; 3) Learn the newest treatments for PTSD million children requiring care. Given this extreme and depression related to war and re-integration workforce shortage, many children are seen by non- with home; 4) Know the role of integrated and new child and adolescent psychiatrists, including general treatments for PTSD; and 5) Learn how to decrease psychiatrists and pediatricians. Child psychiatric barriers to care for servicemembers. strategies for treatment. Important programs in the SUMMARY: military will be outlined. The Long War began with 9/11. PTSD, traumatic brain injury (TBI), and suicide have emerged over the National Institutes of Health Town Hall: Hear From last 15 years of war as monumental issues for our Leadership servicemembers, veterans, and their families. About Presenters: Wilson M. Compton, M.D., Robert 2.7 million servicemembers have served in Iraq, Huebner, Ph.D., Robert Heinssen, Ph.D. Afghanistan, and other locations. About 15% of those who have been in combat have PTSD EDUCATIONAL OBJECTIVE: symptoms. During the wars in Afghanistan and Iraq, At the conclusion of this session, the participant unanticipated and extended deployments were should be able to: 1) Identify and understand extremely taxing for military families. The U.S. priorities for drug abuse research, including how the military has developed many programs to prepare shifting legal and policy environment regarding servicemembers for combat and to treat those with cannabis may impact psychiatric health and how combat-related PTSD and depression. These will be psychiatry can play a role in addressing the opioid described here in more detail. The wars are now crisis; 2) Identify and understand priorities for winding down. Re-integration with home is a mental health research, including new approaches continuing problem with barriers to care and stigma. for translating scientific findings into effective The rising suicide rate among servicemembers and interventions that improve the treatment and veterans has been a major concern for all in the prevention of serious mental illness; and 3) Identify military. The combination of unit and individual risk and understand priorities for alcohol research, factors for suicide include the high operations including a focus on heavy alcohol consumption by tempo, feelings of disconnectedness on return persons with co-occurring mental illnesses. home, problems at work or home, pain and disability, alcohol, and easy access to weapons. SUMMARY: Opioid addiction is a growing problem. Fortunately, Improving mental health services depends on there are emerging effective treatments for PTSD rigorous science which is often supported by the and TBI. Established evidence-based therapies are National Institutes of Health. Come meet leadership effective in most cases, but only if the from the National Institute on Drug Abuse (NIDA), servicemember completes the treatment. We have the National Institute of Mental Health (NIMH) and also learned clinical pearls for treating those with the National Institute on Alcohol Abuse and PTSD. Medication, psychotherapy, and alternative Alcoholism (NIAAA) at this interactive town hall treatments are all helpful. While only two SSRIs session with: NIDA Deputy Director Dr. Wilson (sertraline and paroxetine) are FDA approved, many Compton, NIMH Director of the Division of Services others are commonly used. We have found and Intervention Research Dr. Robert Heinssen, and bupropion especially useful. However, many NIAAA Acting Director of the Division of Treatment servicemembers are noncompliant, either because and Recovery Research Dr. Robert Huebner. Drs. they dislike the therapy or develop sexual side Compton, Heinssen and Huebner will provide brief effects to medications. There are strategies to updates about their institute's scientific priorities as decrease the sexual side effects. Off-label use of they relate to behavioral health, and the session will medications can be very helpful for PTSD and TBI, then include an open discussion with the audience. including second-generation antipsychotics for PTSD Science is moving forward quickly and making sure and stimulants for TBI. Polypharmacy will likely be that the topics and issues of importance to you are beneficial. Innovative, but not yet scientifically addressed is key. Bring questions for the open understood, approaches include acupuncture, discussion. NIH wants to hear from you! stellate ganglion block, mindfulness, canine therapy, equine therapy, and others that help engage the Friday, October 20, 2017 patient. This forum will briefly describe psychological reactions to war and reintegration and emerging SAMHSA Town Hall: Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) Updates Saturday, October 21, 2017 Chair: Anita Everett, M.D. Presenters: Justine J. Larson, M.D., David Addressing Barriers to Clozapine Underutilization: A DeVoursney, M.P.P. National Effort Presenters: Brian Hepburn, M.D., Raymond C. Love, EDUCATIONAL OBJECTIVE: Pharm.D., Deanna L. Kelly, Pharm.D. At the conclusion of this session, the participant Discussants: Andrew McLean, M.D., M.P.H., should be able to: 1) Identify and improve mental Frederick C. Nucifora Jr., D.O., Ph.D., M.H.S. health disparities in; the community; 2) Demonstrate and apply new skills that will be useful in public EDUCATIONAL OBJECTIVE: psychiatry settings; 3) Examine how the current At the conclusion of this session, the participant health care system affects patient care; 4) Describe should be able to: 1) Discuss the utility of clozapine how to transform systems of care; and 5) Recognize in the treatment of serious mental disorders; 2) List how to bring new innovations into a variety of barriers to the use of clozapine; 3) Explain new treatments to improve patient care. guidelines and requirements for clozapine monitoring in the U.S., including the impact and SUMMARY: recognition of benign ethnic neutropenia; and 4) The ISMICC reports to Congress and federal agencies Recognize national efforts to increase access to on issues related to serious mental illness (SMI) and clozapine, including the development of a white serious emotional disturbance (SED). The ISMICC is paper and collaborative strategies to improve composed of senior leaders from 10 federal agencies utilization. including HHS, the Departments of Justice, Labor, Veterans Affairs, Defense, Housing and Urban SUMMARY: Development, Education, and the Social Security Clozapine is the most effective antipsychotic for Administration along with 14 non-federal public patients with treatment-resistant schizophrenia. members. Treatment guidelines recommend that a clozapine trial should be given to all eligible patients after Supporting Medical Directors in Behavioral Health failing two antipsychotic trials. Data on clozapine's Clinics cost effectiveness is growing as two recent Chair: Saul Levin, M.D., M.P.A. publications tout significant costs savings. Clozapine can cause a variety of unique and serious side EDUCATIONAL OBJECTIVE: effects. The U.S. Food and Drug Administration (FDA) At the conclusion of this session, the participant mandates registry-based monitoring of the absolute should be able to: 1) Describe challenges faced by neutrophil count (ANC) for the duration of treatment directors of behavioral health clinics. with clozapine due to the risk of severe neutropenia. A host of potentially serious side effects requires a SUMMARY: thorough consideration of both its risks and benefits, This session is open to APA members who are active a thoughtful patient-centered approach, and a medical directors in behavioral health clinics. In a system that facilitates safe and appropriate use of small group discussion with APA CEO and Medical clozapine. Risk-benefit discussions regarding the use Director Saul Levin, medical directors will have an of clozapine often ignore the psychiatric and medical opportunity to discuss challenges faced in the risks of not using clozapine, such as the impact of community setting and to brainstorm ways in which inferior treatment on the patient's functioning, the the APA might be able to assist. Topics for discussion medical risks from the use of higher than approved include administrative and payment challenges faced doses of antipsychotics, and the frequently in the FQHCs, challenges related to staff recruitment, employed practice of polypharmacy. Despite the contracting, workforce development, and leadership overwhelming evidence of clozapine's superiority development. and its availability in generic form, clozapine is prescribed infrequently in the U.S. compared to an opportunity to engage members of the APA other countries. Recent Medicaid and pharmacy Leadership and APA Administration to discuss ways prescription data from all 50 states found that only in which the APA can assist members in improving six states used clozapine at a rate of 10% or higher. their practices, addressing administrative burdens, Other data suggest that many schizophrenia patients and addressing issues related to burnout and well- have at least three trials and inadequate treatment being. Building on Dr. Everett's theme of "Enhancing for years prior to clozapine initiation. Clinically and Access and Effective Care," panelists will discuss how administratively, a wide variety of barriers to the use the APA's PsychPRO registry can help meet quality of clozapine exist, but few large-scale studies reporting requirements, the efforts of the APA's examine this issue. The barriers include provider, Workgroup of Psychiatrist Well-Being and Burnout, patient and family issues, resource availability, and recent changes in payment reform that allow for health system factors, and administrative burdens, the use of new collaborative care codes. Attendees while the recently introduced clozapine REMS will be encouraged to share concerns and provide system can present additional barriers to clozapine feedback to panelists. use and the recognition of less stringent monitoring requirements for those with benign ethnic Learning Labs neutropenia may help increase access. The National Association of State Mental Health Program Thursday, October 19, 2017 Directors (NASMHPD) convened a national workgroup to identify barriers and make "Cloaks and Clergies”: The Case of Patient B recommendations to improve clozapine use. This Chair: Lawrence McGlynn, M.D. group of clinicians, researchers, and clinical administrators published a series of EDUCATIONAL OBJECTIVE: recommendations targeted at various groups with At the conclusion of this session, the participant the power to increase access to and improve should be able to: 1) Provide culturally competent clozapine use. NASMHPD has begun efforts to care for diverse populations; 2) Integrate knowledge reduce and address the barriers and implement of current psychiatry into discussions with patients; selected recommendations to improve use and and 3) Identify barriers to care, including health access to clozapine. This forum will focus on service delivery issues. clozapine, its barriers, new monitoring issues, NASMHPD's efforts, and strategies to overcome SUMMARY: underutilization and improve treatment with this A highly interactive learning lab that will push evidence-based treatment. attendees to use their medical and investigative skills to solve the complicated medical history of an Inside the APA Town Hall: A Discussion of anonymous patient. During this fun and engaging Innovation Efforts to Improve Your Practice session, team up with fellow colleagues to solve Chairs: Anita Everett, M.D., Saul Levin, M.D., M.P.A. clues, role play, brainstorm and interrogate Presenters: Richard F. Summers, M.D., Philip Wang, characters from the patient’s life, and put your M.D., Kristin Kroeger sleuthing skills to the test in this mystery of Sherlock Holmes proportions. Each participant will work EDUCATIONAL OBJECTIVE: through a complex case and through the process of At the conclusion of this session, the participant deduction determine the medical history of a real- should be able to: 1) Describe initiatives within the life patient. You will learn and practice necessary APA that are designed to assist members address critical thinking skills while diving deep into this issues related to payment reform, physician well- gripping tale of medical mystery. being and burnout, and the PsychPRO registry. Friday, October 20, 2017 SUMMARY: This interactive session will provide members with Innovation and Design Thinking in Mental Health Care innovation is particularly difficult in the health care Presenter: J. Andrew Chacko, M.D., M.S.E. space and will discuss design thinking as a process for innovation. Doctoring is very much like designing, EDUCATIONAL OBJECTIVE: and a better understanding of design can help us as At the conclusion of this session, the participant we craft treatment plans and increase patient should be able to: 1) Understand what innovation engagement. Among clinicians, as psychiatrists, we and design thinking really are and what role they can are particularly well suited for the first and possibly play in the future of mental health care; 2) most critical step in design--to truly understand the Understand some of the barriers to innovation in problem--and that can put us at the helm, shaping health care; and 3) Learn and practice some basic the course not only of our discipline, but of medicine tools of design thinking and understand how it can in general. We will learn and practice some of the greatly improve your patient engagement, transform same tools to enhance creative problem solving that your practice and reshape your personal life. the leading design firms in Silicon Valley use and apply them to problems we encounter in our SUMMARY: practice. Innovative thinking can not only reshape What is innovation? How is innovation in health care your practice but can transform your personal life as different? Why is it important for us as psychiatrists well. And for a select few, whom these ideas ignite, to understand? We will answer all those questions it may radically alter your career. and more. The word innovation is so overused that it seems to have lost all meaning. And yet, if you are Medical Director Boot Camp Day 1: Basics and the an outsider, it can feel quite daunting--something to Medical Director as Educator do with technology and apps and interoperability. In Chair: John Kern, M.D. this session, we will dig through all the Presenters: Joseph Parks, M.D., Lori Raney, M.D. misconceptions to arrive at what it really means. Simply put, innovation is a novel way to solve a EDUCATIONAL OBJECTIVE: problem. By first looking at other industries, we can At the conclusion of this session, the participant delve into why innovation is critically important for should be able to: 1) Describe the unique role of the us to understand and embrace. An inability to psychiatric medical director in mental health and innovate and anticipate the future led to the medical organizations; 2) Understand the potential collapse of titans of industry like Kodak and of the ECHO model to expand psychiatric expertise Blockbuster, while the opposite propelled young across under-supplied treatment organizations; and companies like Uber and AirBNB to the front of their 3) Identify basic human resources functions required respective packs. Interestingly, as physicians, we of a psychiatric medical director. may feel secure in our field. Or are we? We will look at some of the companies/technologies that are SUMMARY: driven by personal experience or lured by a piece of Join us on Friday and Saturday for a special Medical the $3.1 trillion U.S. health care pie. While we sit Directors' Boot Camp. Speakers from university here, hundreds of software, hardware and app medical programs, hospitals, and leadership training developers are trying to find better solutions to programs will offer an interactive way to learn the delivering mental health care that is more accessible, important aspects of what it means to be a affordable and even fun for their clients. Even many psychiatric medical director who can function of our patients, disgruntled with the state of mental effectively as a leader. Participants will learn the health care, are out looking for "better" answers basics of how to handle staff and subordinates, as than we are providing. We will see how fellow well as higher-level strategies to expand the role and clinicians--NPs, psychologists, pharmacists, social influence of the psychiatric medical director across workers, MFTs--have already greatly modified our the medical spectrum, and to address burnout in roles. So how do we navigate this new world? Better both the medical director and the psychiatric staff still, how do we master it? This highly interactive they supervise. A significant part of these sessions workshop will look at the fundamental reasons why will also involve peer-to-peer networking, allowing attendees to build their contacts to help them Lecturer: James L. Griffith, M.D. address the tricky issues that arise when you're the medical director in a bustling clinical setting. EDUCATIONAL OBJECTIVE: At the conclusion of this session, the participant Saturday, October 21, 2017 should be able to: 1) Distinguish demoralization as a normal syndrome of distress from depression and Medical Director Boot Camp Day 2: Special other psychiatric illnesses with low mood; 2) Populations and Sustainability Conceptualize hope as a practice, i.e., “something Chair: John Kern, M.D. you do” rather than “something you feel”; 3) Presenters: Ruth Shim, M.D., M.P.H., Richard F. Conduct an assessment of a person’s signature Summers, M.D., William Chandler Torrey, M.D. strengths for mobilizing hope; 4) Construct brief psychotherapeutic interventions that help a patient EDUCATIONAL OBJECTIVE: to mobilize hope when confronted by adversities; At the conclusion of this session, the participant and 5) Engage patients’ spiritual resources as a should be able to: 1) Identify strategies to address source for hope practices that can be incorporated the impact of the social determinants of mental into brief psychotherapeutic interventions for health on their organizations and patients; 2) Discuss mobilizing hope. issues particular to psychiatric medical directors working in the VA system; and 3) Enumerate SUMMARY: strategies to address burnout in themselves and in Despair from demoralization is a constant threat to their medical staff members. patients with chronic mental illnesses, refugees fleeing persecution, elderly who are socially isolated, SUMMARY: the medically disabled, and other marginalized or Join us on Friday and Saturday for a special Medical displaced people. These individuals often face Directors' Boot Camp. Speakers from university pileups of acute and chronic stressors, including medical programs, hospitals, and leadership training unsafe living conditions, loneliness, limited access to programs will offer an interactive way to learn the health care, and loss of social status or familiar important aspects of what it means to be a identities. Demoralization refers to the helplessness psychiatric medical director who can function and incompetence that people feel when sensing effectively as a leader. Participants will learn the that they are failing to cope. The resulting despair basics of how to handle staff and subordinates, as produces avoidance and resignation when facing well as higher-level strategies to expand the role and adversity, rather than assertive coping. Hope is a influence of the psychiatric medical director across natural antidote for despair. However, hope can be the medical spectrum, and to address burnout in ephemeral, or worsens despair, when life both the medical director and the psychiatric staff circumstances cannot be controlled. Hope modules they supervise. A significant part of these sessions are resilience-building psychotherapeutic will also involve peer-to-peer networking, allowing interventions that strengthen morale by mobilizing a attendees to build their contacts to help them person's strengths for sustaining hope. Hope address the tricky issues that arise when you're the modules package skill sets for assessment, medical director in a bustling clinical setting. formulation, and intervention around a single evidence-based hope practice. Evidence-based hope Lectures practices were identified from psychological studies of resilient individuals and research literature of Thursday, October 19, 2017 cognitive and social neuroscience, palliative care, psychosomatic medicine, and psychotherapy Hope Modules: Brief Psychotherapeutic outcome studies. Hope modules address hope as a Interventions to Counter Despair From Chronic practice, rather than an emotional response to life Adversities circumstances, i.e., "something you do" rather than Chairs: John Peteet, M.D., Clark Aist, Ph.D. "something you feel." Hope as a practice can be sustained despite ongoing stressors, emotional organizations, crisis services and primary care depletion, or numbness from trauma. Hope modules practices. The Zero Suicide framework's seven pillars can be tailored to the specific predicaments with (Lead, Train, Identify, Engage, Treat, Transition and which a person is struggling. Assessment, Improve) establishes ways to operate within a care formulation, and intervention are conducted by system that is safer for patients at risk for suicide, observing whether a person's immediate coping and thereby, to substantially reduce the number of response to extreme stress best reflects strategies suicide deaths and suicide attempts of those in care. for individual problem solving and goal seeking The risk of suicide attempts and death is highest (executive functions), relational coping within the first 30 days after a person is discharged (interpersonal social cognition), activating a core from an ED or inpatient psychiatric unit, yet as many identity (social cognition of identity), or emotion as 70 percent of suicide attempt patients of all ages regulation. This initial response points to the never attend their first outpatient appointment. probable domain for signature strengths that can Therefore, access to clinical interventions and mobilize hope. The clinician then helps the person to continuity of care after discharge is critical for intensify use or expand scope of similar hope preventing suicide. It is imperative that various practices from this domain. Hope modules fill a providers who engage with behavioral health practice gap by providing psychotherapeutic patients work closely and that behavioral health interventions that help a person struggling against systems of care weave comprehensive suicide harsh or chronic adversities to sustain morale and prevention into the fabric of all aspects of avoid despair. operations. Speakers will describe the Zero Suicide in Health and Behavioral Health Care framework and Zero Suicide in Health and Behavioral Healthcare: A give an example of it's implementation within a large Provider's Journey outpatient behavioral health organization, their Chair: Peter L. Chien, M.D. results/analytics related to suicide deaths in this Lecturers: Karen Rhea, Becky Stoll, L.C.S.W. organization and discuss how to overcome the barriers that exist to providing safer suicide EDUCATIONAL OBJECTIVE: prevention care. At the conclusion of this session, the participant should be able to: 1) Emphasize extent to which a Friday, October 20, 2017 thoughtful, meaningful, and systematic Zero Suicide in Behavioral Healthcare approach saves lives for Collaborating With the Cops: The Crisis Intervention those at risk for suicide; 2) Describe the seven pillars Team (CIT) Model of Specialized Police Response to and their components in the Zero Suicide in Persons With Mental Illnesses Behavioral Healthcare framework that can be used Chair: Grayson Norquist, M.D., M.S.P.H. in different treatment settings; 3) Offer ways to build Lecturer: Michael T. Compton, M.D., M.P.H. a suicide safer care model of suicide prevention to establish minimal standards for operating a system EDUCATIONAL OBJECTIVE: of care for individuals at risk of suicide; and 4) Share At the conclusion of this session, the participant resources that exist to help providers and should be able to: 1) Describe key elements of the organizations improve their care management Crisis Intervention Team (CIT) model; 2) Identify at strategies for patients at risk for suicide. least three key research findings on CIT; and 3) Understand the importance of CIT for facilitating SUMMARY: access to appropriate psychiatric services. The goal of this session is to highlight the Zero Suicide in Health and Behavioral Health Care SUMMARY: framework which is being implemented across the The Crisis Intervention Team (CIT) model has United States in organizations such as emergency become the leading form of law enforcement- department (ED) providers, inpatient psychiatric mental health collaboration in the U.S. and has been settings, outpatient behavioral health care implemented in numerous municipalities across the country. Many police forces are seeking to train Lecturer: Patrice A. Harris, M.D., M.A. approximately 20% of officers using the 40-hour CIT curriculum; others are training all new recruits. The EDUCATIONAL OBJECTIVE: training, along with local reforms in both police and At the conclusion of this session, the participant mental health policies and procedures, aims to should be able to: 1) Explain the role of the AMA improve officer and patient safety, enhance access Opioid Task Force; 2) Identify the actions that to mental health services, and reduce unnecessary physicians can take to reverse the nation’s opioid arrest and incarceration for minor infractions by epidemic; 3) Discuss the data demonstrating people with serious mental illnesses. Given the physicians’ work to reverse the epidemic; and 4) enthusiasm for CIT from advocates, law enforcement Highlight areas that must still be addressed to and other public safety personnel, and mental health ensure access to treatment for patients. professionals—and in light of the increasing pace of implementation of this complex collaboration in a SUMMARY: multitude of localities across the country—this The American Medical Association (AMA) Opioid lecture provides an overview of the program and Task Force formed in 2014 to coordinate the efforts recent research findings. In one of Dr. Compton's of the nation's medical societies to combat the large studies, 251 CIT-trained officers had growing opioid misuse, overdose, and death consistently better scores on knowledge, diverse epidemic. The task force includes the AMA and more attitudes toward mental illnesses and their than 25 state, national, and specialty medical treatments, self-efficacy for interacting with societies, including the American Psychiatric someone with psychosis or suicidality, social Association. The task force recognized that many distance stigma, de-escalation skills, and referral physician organizations were taking action to help decisions compared to 335 non-CIT officers. Effect educate physicians about the growing epidemic, but sizes for some, including de-escalation skills and there was a need to combine efforts and amplify the referral decisions pertaining to psychosis, were voice of organized medicine and physician substantial (d=0.71 and 0.57, respectively, both leadership. In 2015, the task force issued five p<0.001). In another of Dr. Compton's studies recommendations: 1) Encourage physicians to use involving 1,063 encounters, CIT-trained officers were prescription drug monitoring programs (PDMPs); 2) significantly more likely to report "verbally engaged, Enhance education to help ensure the most negotiated with the subject" as the highest level of appropriate prescribing decisions; 3) End the stigma "force" used. Referral to services or transport to a of pain and support comprehensive pain care, treatment facility was more likely (OR=1.70, including non-opioid and nonpharmacological p=0.026) and arrest less likely (OR=0.47, p=0.007) treatment(s); 4) End the stigma of substance use when encounters involved CIT-trained officers disorders and increase access to comprehensive compared to non-CIT officers; moreover, these treatment, including mental and behavioral health findings were most pronounced when force was care; and 5) Increase access to naloxone and broad necessary. Two other studies examining models good Samaritan laws to help save lives from explaining how CIT training might achieve these overdose. In 2017, the task force issued a new results will also be reviewed. Although findings are recommendation to urge physicians to talk to their accumulating, additional research on this rapidly patients about safe storage and disposal of opioids expanding collaborative service model is of utmost and all medications to reduce the risks associated importance. CIT is an important avenue for with unwanted, unused, and expired medications. collaboration between community psychiatrists, Legislatures have also enacted many new laws and health services researchers, advocates, and law other requirements to regulate physician behavior. enforcement and other public safety professionals. These include new mandates to use PDMPs and new restrictions on opioid prescribing. Access to Physicians’ Work to Reverse the Nation’s Opioid naloxone has also greatly expanded. With only a few Epidemic exceptions, there has been little action on increasing Chair: Michael T. Compton, M.D., M.P.H. access to treatment, although passage of the federal Comprehensive Addiction and Recovery Act and and early mortality for patients with serious mental subsequent funding may help. As state laws and illness. national attention have increased commensurate with growing opioid-related overdose and mortality, Saturday, October 21, 2017 it is critical to review the data. Generally, physician efforts began prior to enactment of the new laws Impact of Trauma: From Molecules to Communities mandating physician actions. This includes increases Chair: Michael Flaum, M.D. in PDMP use, decreases in opioid prescriptions, and Lecturer: Kerry Ressler, M.D., Ph.D. increases in lives saved through naloxone. The data also show a large increase in physicians trained to EDUCATIONAL OBJECTIVE: provide in-office buprenorphine for the treatment of At the conclusion of this session, the participant substance use disorders, but it is unclear whether should be able to: 1) Describe new research across private and public payer policies have changed to patient populations and animal models in the truly allow for patients to access care. There is great neurobiology of PTSD; 2) Discuss the impact of concern about the changing nature of the epidemic poverty, cycles of violence, and trauma exposure on and the growing mortality rates due to heroin and risk for civilian PTSD; and 3) Educate others on illicit fentanyl. There are also increasing concerns potential new treatment methods, as well as further about patients losing access to care, as physicians understanding current approaches to treating PTSD. and other health care professionals may no longer be providing pain care due to fear and other SUMMARY: concerns. To reverse the epidemic, physician Exposure to traumatic events during development leadership must continue, and considerable has consistently been shown to produce long-lasting attention must be focused on ensuring access to alterations in the hypothalamic-pituitary-adrenal comprehensive pain care and patient access to (HPA) axis and other stress pathways. Furthermore, treatment for substance use disorders. substantial data document high levels of childhood and adult trauma exposure, principally interpersonal Psychiatry’s Role in Addressing the Physical Health violence, among impoverished, urban communities. Status of Patients With Serious Mental Illness Within this population, the level of ongoing stress Chair: Alvaro Camacho, M.D., M.P.H. increases vulnerability to disease, including Lecturer: Benjamin G. Druss, M.D., M.P.H. posttraumatic stress disorder and other mood and anxiety disorders. Data suggest that molecular EDUCATIONAL OBJECTIVE: pathways regulate stress function in conjunction At the conclusion of this session, the participant with exposure to child maltreatment or abuse. In should be able to: 1) Understand the burden of poor addition, a large and growing body of preclinical physical health and early mortality among patients research suggests that increased activity of the with serious mental illness; 2) Understand the amygdala-HPA axis induced by experimental behavioral, health care, and social factors manipulation of the amygdala mimics several of the contributing to poor physical health and early physiological and behavioral symptoms of stress- mortality among patients with serious mental illness; related psychiatric illness in humans. These 3) Identify evidence-based approaches to addressing translational findings lead to an integrated poor physical health and early mortality among hypothesis: high levels of early life trauma lead to patients with serious mental illness; and 4) Identify disease through the developmental interaction of emerging roles for psychiatrists in addressing poor genetic variants with neural circuits that regulate physical health and early mortality among patients emotion, together mediating risk and resilience in with serious mental illness. adults. This lecture will review the effects of trauma on molecular systems to neural circuits and how this SUMMARY: impacts communities devastated by high levels of This lecture will discuss clinical, research, and policy trauma and violence. developments in addressing poor physical health At the conclusion of this session, the participant Psychiatric Services Achievement Award Winners: should be able to: 1) Describe different models of Innovation in Service Delivery integrated care; 2) Describe the rationale for child psychiatry access programs; and 3) Describe the No. 1 structure, evolution, and results of CAP PC, a large APA Gold Award: Service Program for Older People scale child psychiatry access program in New York (SPOP) and Strategies to Increase Access to Mental state. Health Care for Older Adults Lecturer: Nancy Harvey, L.M.S.W. SUMMARY: Objective: Although child mental health problems EDUCATIONAL OBJECTIVE: are widespread, few get adequate treatment, and At the conclusion of this session, the participant there is a severe shortage of child psychiatrists. To should be able to: 1) Identify strategies for service address this public health need many states have delivery to community-dwelling older adults; 2) adopted collaborative care programs to assist Identify effective partnerships to increase access to primary care to better assess and manage pediatric mental health care; and 3) Identify strategies to mental health concerns. This report adds to the reduce stigma associated with mental illness in a small literature on collaborative care programs and geriatric population. describes one large program that covers most of New York state Methods: CAP PC, a component SUMMARY: program of New York State's Office of Mental Health Older adults are at increased risk for developing (OMH) Project TEACH, has provided education and behavioral health disorders, often due to physical consultation support to primary care providers in decline, loss of a loved one, or social isolation. 90% of New York state since 2010. The program is Community-dwelling older adults present a uniquely a five medical school collaboration with challenge to the mental health professional, as they hubs at each that share one toll free number and are often difficult to identify and/or are reluctant to work together to provide education and consultation seek treatment. Service Program for Older People support services to PCPs. Results: CAP PC has grown (SPOP) has developed strategies to identify at-risk over the 7 years of the program and has provided seniors, provide information, reduce stigma, and 8957 phone consultations to over 1600 PC Ps. The deliver service either in the home or at a program synergistically provided 18,038 CME credits neighborhood senior center. Working with medical of educational programming to 1200 PCPs. PCP users providers, social service agencies, government of the program report very high levels of satisfaction entities, and senior centers, SPOP has successfully and self reported growth in confidence. Conclusions: reduced hospitalization rates, increased social CAP PC demonstrates that large-scale collaborative connectedness, and improved overall well-being for consultation models for primary care are feasible to this population. This presentation will review how implement, popular with PCPs, and can be sustained. SPOP developed partnerships with Mount Sinai The program supports increased access to child Visiting Doctors, the New York City Department for mental health services in primary care and provides the Aging, SAGE/Services and Advocacy for GLBT child psychiatric expertise for patients who would Elders, and other organizations to meet the need for otherwise have none. community-based geriatric mental health care. No. 3 No. 2 Improving Access to Treatment for Perinatal Mental CAP PC: New York State’s Multi-University Health and Substance Use Disorders: A Look at Education and Collaborative Care Child Psychiatry MCPAP for Moms Access Program Lecturer: Nancy Byatt, D.O, M.B.A., M.S. Lecturer: David L. Kaye, M.D. Co-Authors: Tiffany A. Moore-Simas, John H. Straus

EDUCATIONAL OBJECTIVE: EDUCATIONAL OBJECTIVE: At the conclusion of this session, the participant set the context for the development of MCPAP for should be able to: 1) Provide background Moms, describe the process of implementation, and information on the public health relevance of present the first three years of program utilization perinatal depression, particularly to obstetric data. We will review lessons learned during providers; 2) Describe the development, implementation of MCPAP for Moms, future implementation and outcomes of a low-cost directions, and how it can serve as a model for other population based program to address perinatal states. depression, the Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms); and No. 4 3) Discuss how the MCPAP for Moms model can be Closing the Early Psychosis Treatment Gap and leveraged to increase access to perinatal psychiatric Preventing Disability care in other states. Lecturer: Jean-Marie Bradford, M.D. Presenter: Nannan Liu, Ed.D. SUMMARY: Despite routine contact with medical care through EDUCATIONAL OBJECTIVE: obstetrical providers, the majority of women with At the conclusion of this session, the participant perinatal depression do not receive treatment due should be able to: 1) Learners will understand the to multi-level barriers. Screening for perinatal concept of coordinated specialty care (CSC); 2) depression alone does not improve treatment rates Learners will understand the core components of the or patient outcomes. Addressing the multi-level OnTrackNY/WHCS CSC model for treatment of early barriers to treatment will ultimately require a psychosis; 3) Learners will be understand three practical and sustainable platform. In this session, evidence based practices that can be implemented we will describe a statewide program, the treatment of individuals with early psychotic Massachusetts Child Psychiatry Access Program for symptoms; and 4) Learners will be able to describe Moms (MCPAP for Moms), that addresses this major three resources to help implement evidence based public health need by providing: 1) trainings and practices and CSC models for early psychosis. toolkits for providers on evidence-based guidelines for screening, assessment and treatment or SUMMARY: perinatal mental health and substance use disorders; Approximately 100,000 adolescents and young 2) access to real-time telephonic psychiatric adults in the US experience first episode psychosis consultation for providers serving pregnant and (FEP) each year. There is a growing effort to postpartum women; and, 3) care coordination. Since decrease the often long delays between onset of its launch in July 2014, MCPAP for Moms has psychotic symptoms and initiation of treatment in enrolled 122 Ob/Gyn practices accounting for >80% order to reduce the burden of illness. The of deliveries in the state, conducted 133 trainings, OnTrackNY model for treatment of first episode provided 2,696 care coordination activities and psychosis was created by a team led by Lisa Dixon, 1,690 phone consultations, serving 2,383 perinatal MD, and grew out of the NIMH-funded research women. The total cost of the program, including study, Recovery after Initial Schizophrenia Episode administrative expenses, is $11.81 per perinatal (RAISE). Embedded in the Washington Heights woman per year ($0.98 per month) or $850,000 for Community Service (WHCS) at New York State 72,000 deliveries annually in Massachusetts. The Psychiatric Institute, OnTrackNY/WHCS began in presentation will discuss sustainability including October 2013 and was one of four initial sites for the Massachusetts surcharge on commercial insurers. OnTrackNY model. OnTrackNY/WHCS is an MCPAP for Moms led to the recently passed federal innovative, multidisciplinary team approach to HR. 3235, Bringing Postpartum Depression Out of providing recovery oriented treatment to young the Shadows Act of 2015 (consolidated in the 21st people aged 16-30 who are within two years of first Century Cures Act), which will appropriate experiencing psychotic symptoms. OnTrackNY/WHCS $25,000,000 over 5 years to establish MCPAP for is a Coordinated Specialty Care (CSC) model, which Moms-type programs. In this presentation, we will provides a package of specific services to treat early psychosis, emphasizing evidence-based treatments who are homeless, or have been involved in the in a team based format for two years. Components criminal justice system; and 4) Understand best of the CSC model include medication management, practices, as well as the systems barriers that exist supported employment and education, cognitive and and need to be addressed. behaviorally based relapse prevention, illness management, integrated substance abuse SUMMARY: treatment, case management, suicide prevention, For over 60 years, State Public Mental Health and family intervention and support. Services are Systems across the nation have been transitioning provided in individual and group formats according from inpatient institutional care for individuals with to consumers' preferences. OnTrackNY/WHCS has serious mental illness to community-based care achieved measurable success in multiple quality focused on recovery and successful integration into measures. OnTrackNY/WHCS has proven to be community life. While the media discussions often effective at helping participants improve quality of focus on the reduction of inpatient psychiatric beds life and achieve educational and occupational goals, in what were former large institutions, these doubling rates of work or school enrollment from discussions have missed the story of significant 40% to 84% at one year of treatment. Efforts to investments in community based care and recovery engage patients and families have proven to be that have enabled so many individuals with serious successful, visiting all participants in the community mental illness to live successful lives in the at least once, maintaining engagement and community. We are in a time when best practices in providing family support to over 85% of participants. making community based care successful are well Through this high engagement, we have been able known, but unfortunately not always financed or to decrease emergency room (ER) utilization from implemented to the extent needed. While there has 80% of participants with one or more ER visits on been significant progress, we are still faced with admission to the program to 14% over the course of serious challenges in providing a robust continuum treatment. We have also been able to decrease of care that can also meet the needs of individuals inpatient hospitalization rates from 66% of with serious mental illness who are involved with the participants with one or more hospitalizations to criminal justice system or who are homeless and 10% over the course of treatment. disconnected from community. We are also challenged to ensure that the services we provide State Public Mental Health Systems: Past, Present, truly integrate care for the whole individual, and Future including behavioral health and physical health. Chair: Ruth Shim, M.D., M.P.H. Furthermore, early intervention and prevention of Lecturer: Ann Marie T. Sullivan, M.D. serious mental illness need to be infused in our systems of care. This lecture will focus on the EDUCATIONAL OBJECTIVE: successes as well as the challenges faced by State At the conclusion of this session, the participant Public Mental Health Systems, and discuss models of should be able to: 1) Gain knowledge of the history service that in the future could provide a continuum of State Public Mental Health Systems and their of care for individuals where hospital beds are transition to the current philosophy of integrated, available when needed, followed by successful community-based care and inclusion; 2) Gain transitions to care and inclusion in the community. knowledge of the best practices in an integrated continuum of community care, including hospital- Update on Electroconvulsive Therapy (ECT) based care when needed, that have enabled Chair: Robert Osterman Cotes, M.D. individuals to live full and productive lives in the Lecturer: Charles H. Kellner, M.D. community, with some focus on initiatives in New Presenters: Robert M. Greenberg, M.D., Adriana York State; 3) Be engaged in a discussion of the Hermida, M.D. continuing challenges in the transition to community-based care, especially the challenges EDUCATIONAL OBJECTIVE: facing individuals living with serious mental illness At the conclusion of this session, the participant should be able to: 1) Understand the clinical that focuses on the interface between psychiatry indications for ECT; 2) Discuss with patients the likely and the law. It may involve the evaluation of adverse effects of ECT and how to manage them; individuals involved in the legal system, working in and 3) Understand the ongoing role of stigma in the juvenile correction facilities, involved in legal issues underutilization of ECT. related to practice teaching, and performing research. Traditionally, child and adolescent forensic SUMMARY: psychiatry has focused on issues of child abuse, Electroconvulsive therapy (ECT) remains an neglect, custody, and delinquency. Beginning in the indispensable treatment in modern psychiatric early 1980s, many child and adolescent psychiatrists medicine. For treatment-resistant depression and a were drawn into civil suits as expert witnesses in limited number of other severe psychiatric illnesses, child custody cases during divorce proceedings and it is the most effective and rapidly acting therapeutic cases alleging child sexual abuse. Civil litigation modality. Advances in ECT technique have made the involving youth has expanded, including suits for treatment even safer and better tolerated than in psychic trauma, malpractice, and class action suits the past. Stigma and lack of familiarity with against institutions for neglect and abuse. The contemporary ECT techniques are the most evaluations done for the criminal courts have also significant barriers to the appropriate prescription of changed. Competency examination evaluations have ECT in the U.S. and around the world today. In this changed so that it is now important to consider the lecture, the speakers will provide an overview of developmental age of the juvenile in the assessment. ECT, with a review of clinical indications and an Most importantly for youth tried as adults, forensic update on modern ECT technique. Data from recent evaluations are increasingly utilized in sentencing ECT clinical trials will be presented. The logistics of a decisions. Two important decisions, Roper v. course of ECT and the clinical decision making during Simmons (2005) and Grahm v. Florida, have the course of treatment will be discussed in detail. supported the understanding of why adolescents Common treatment-emergent adverse effects and think and behave differently than adults. In their management will be covered, so that the particular, in Grahm, the Court held that a sentence referring practitioner will gain the knowledge of life without parole (LWOP) was unconstitutional needed to support their patient during the course of for all non-homicide offenders. Two years after ECT. The problem of the stigma surrounding ECT will Grahm, in 2012, the Court ruled that, even for be discussed, along with suggestions for overcoming murder, a mandatory LWOP sentence for and combating it. Ample time will be allowed for adolescents was unconstitutional. This has led to questions and audience participation. reevaluations of many juveniles. The future holds promise for increased use of developmental Sunday, October 22, 2017 information in rehabilitating adolescent offenders. In addition, because of the increased frequency of Forensic Child and Adolescent Psychiatry: divorce and the change in family structures, the Contemporary Issues standards for determining child custody and Lecturer: Elissa P. Benedek, M.D. visitation will need to be reviewed and updated to preserve the doctrine of “best interests of the child.” EDUCATIONAL OBJECTIVE: At the conclusion of this session, the participant Measuring Behavioral Health Quality and should be able to: 1) Review child forensic psychiatry Performance: When and Why Does It Matter? in the past; 2) Review present controversies and Chair: Erik R. Vanderlip, M.D., M.P.H. issues in child forensic psychiatry; and 3) Peek into Lecturer: Thomas Smith, M.D. predictions about the future of child and adolescent forensic psychiatry. EDUCATIONAL OBJECTIVE: At the conclusion of this session, the participant SUMMARY: should be able to: 1) Understand current Forensic psychiatry is the subspecialty of psychiatry performance measurement programs used by payers and providers; 2) Become familiar with with a survey of the emerging services research commonly used performance measures and the literature examining the impact of performance processes by which measures are developed; and 3) measurement programs on health care outcomes as Understand current controversies in performance well as a summary of future directions related to measurement as well as efforts underway to develop measure development and use in alternative measures of patient-centered and functional payment models. outcomes related to health care. White Opioids: Lessons on Race from the Overdose SUMMARY: Crisis The focus on value- and person-centered outcomes Chair: Marc Manseau, M.D., M.P.H. in health care is increasing dramatically, best Lecturer: Helena B. Hansen, M.D., Ph.D. exemplified by the U.S. Department of Health and Human Service's goal of tying 85% of all Medicare EDUCATIONAL OBJECTIVE: fee-for-service payments to quality or value by 2016 At the conclusion of this session, the participant and 90% by 2018. This shift has stimulated efforts to should be able to: 1) Participants will be able to develop and implement meaningful health care name three factors leading to the current racial performance measurement strategies. Behavioral demographics of opioid use and overdose; 2) health (BH) has lagged behind general medicine in Participants will be able to articulate the role of the development of performance measures, but racial symbolism in shaping drug policy, regulation recent studies indicate that effective management of and marketing; and 3) Participants will be able to BH conditions will be critical to improve health care describe at least two policy interventions that value across the spectrum of illnesses and treatment promise to rectify the racial inequalities and overall settings. Stakeholders (regulators, payers, and overdose fatalities stemming from current clinical practitioners, including psychiatrists) therefore must practice. address important questions about when and what elements of BH care can and should be measured to SUMMARY: support quality improvement and value-based The current opioid overdose crisis and its focus in payment initiatives. This lecture will describe current white suburban and rural communities raises measurement programs targeting managed care questions about race, drug policy, and addiction organizations, provider networks (including medicine in the U.S. This lecture draws on extensive accountable care organizations), and individual research among pharmaceutical executives, practitioners, including psychiatrists. We will review addiction researchers, drug policy makers, how a measure is "born" (e.g., the screening and prescribing physicians and patients to reconstruct evaluation procedures that lead to measure the role of race in addiction neuroscience, endorsement) and will discuss specific measures biotechnology development, drug regulation and commonly used by providers, managed care marketing, as well as their role in shaping current organizations, and payers, including Medicare and demographic patterns of opioid use and the shifting Medicaid. Current controversies will be reviewed, cultural symbolism of narcotics. Using critical race such as the relative merits of measuring processes theory, analysis of in-depth interviews with key versus outcomes, how to measure quality of care participants in opioid policy and practice, media related to low-frequency outcomes such as suicide coverage of race and opioids, as well as secondary and violence, and the need to limit burden on analysis of epidemiological trends, the lecture providers and payers related to multiple overlapping concludes with counterintuitive conclusions about measures and accountability programs. Particularly the harms of racialized market segmentation to relevant to BH providers, including psychiatrists, is white as well as non-white patients, and the field's lack of tested measures of functioning, recommendations a a re-examination of the tension social connectedness, recovery from chronic illness, between our commodified health care system and and patient-reported outcomes related to public health oriented clinical practice. perception of and involvement in care. We will finish among the legal and legislative communities as well Presentation of Award-Winning Documentary God as the psychiatric profession. It provides an Knows Where I Am unvarnished and unsentimental yet compassionate Chairs: Todd Wider, M.D., Jedd Wider view of its subject, her family, and others who were unable to prevent her death. Context within the film EDUCATIONAL OBJECTIVE: is provided through interviews with prominent At the conclusion of this session, the participant psychiatrists and other nationally recognized should be able to: 1) Understand more clearly the experts. Emblematic of the institutional perils faced systemic failures that lead to negative outcomes for by the severely mentally ill, God Knows Where I Am people with severe mental illness; 2) Understand is a communications tool for educators and more clearly the pivotal role care providers, law treatment professionals to explore and illuminate enforcement, and courts can play in patient these issues. In an era of uncertainty for the future outcomes; and 3) Discuss meaningfully the reasons of health care, this film helps to clarify and prioritize for possible legal changes to existing laws affecting issues of vital importance. patients’ civil rights. Poster Sessions SUMMARY: This media workshop will feature presentation of the Thursday, October 19, 2017 documentary God Knows Where I Am (runtime 97 minutes), followed by Q&A with the filmmakers (15 Poster Session 1 minutes). The body of a homeless woman is found in an abandoned New Hampshire farmhouse. Beside No. 1 her lies a diary that documents a journey of Mail-Order Nootropics: A Case of Tianeptine and starvation and the loss of sanity, but told with Phenibut Abuse and Withdrawal poignancy, beauty, humor, and spirituality. For Poster Presenter: Rachel Hammer, M.D., M.F.A. nearly four months, Linda Bishop, a prisoner of her own mind, survived on apples and rain water, SUMMARY: waiting for God to save her, during one of the Case Description A 25-year-old man from Lebanon coldest winters on record. As her story unfolds from with a past psychiatric of opioid use disorder, PTSD, different perspectives, including her own, we learn major depression refractory to multiple trials of about our systemic failure to protect those who SSRIs and recent suicide attempt by hanging self- cannot protect themselves. A response to the film by presented to our ED with suicidal ideation. The a prominent APA member, Paul S. Appelbaum, M. patient reported that he had been self-medicating D., Dollard Professor of Psychiatry, Medicine, and with tianeptine and phenibut; both medications Law at Columbia University, says “God Knows Where were purchased online. Fear of opioid-withdrawal I Am—beautiful, haunting and supremely moving—is symptoms contributed to his suicidality. He reported one of the most powerful documentary films I have using 4 grams of tianeptine five times daily, and 3 seen on America’s flawed approach to mental health grams daily of phenibut, which cost approximately and homelessness. Essential viewing for anyone $500/week. On admission, his blood pressure was seeking to understand the systemic failings of our 159/92 with tachycardia. Urine drug screen was mental health care system, it is at once a work of art negative (of note, our lab does not assay for the and a clarion call to end our neglect of people with substances he claimed to have used, but the patient mental illnesses. The film powerfully conveys how an did bring in bottles of the product to review). On empty commitment to individual liberty has been initial exam, he was oriented, appeared dysphoric substituted for a genuine system of mental health and had linear thought processes with no treatment and leaves us with one unavoidable hallucinations. His initial CIWA-AR score was 3. He conclusion: we can and must do better.” Presented was given clonidine and chlordiazepoxide on the by the filmmakers themselves, this highly acclaimed second hospital day for CIWA-AR score of 10. The documentary has been the catalyst for discussions next day he had an abrupt and marked change in status. He developed chills, tactile hallucinations, SUMMARY: nausea, diarrhea, abdominal pain, and piloerection. As the expectations for hospital reimbursement shift Over several hours, his mental status deteriorated; to include measures of the quality of care delivered he became disoriented and developed distressing through various metrics, including patient visual hallucinations. On transfer to our ICU for satisfaction, clinicians and administrators must autonomic instability in the setting of severe review and adapt the framework for delivering care. withdrawal, his CIWA-AR was 33. In the ICU, he was In mental health this involves recognizing some of intubated and his vitals stabilized on valium and the unique experiences that influence patients and dexmedetomidine drips, from which he had difficulty color their hospital experience as well as attempting getting weaned over five days. Discussion Nootropics to mitigate how being maintained in a restricted including tianeptine and phenibut are increasingly facility, often against their will, is handled. While recognized as drugs of abuse in the United States. exploring strategies to improve the Patient Nootropics is a new term for "smart drugs," an Experience by developing strategies to listen and emerging class of cognitive-enhancing medications. respond to patient concerns in real-time, it became Tianeptine is a TCA-like and "serotonergic evident that past traumas played a significant role in enhancing" medication prescribed commonly in the shaping the view of the hospital experience. While Middle East and Europe for depression and anxiety. learning how to develop a Trauma-Informed Care Euphoria has been noted at doses greater than 100 Setting it was evident that how moments of crisis are mg (usual maximum daily dose is 50 mg). Tianeptine contained not only defined the experience of the has weak mu-opioid receptor binding at high doses, patient but was heavily influenced by staff and in rats, increases dopamine in the nucleus perceptions of safety and support and their ability to accumbens. Little is known about tianeptine provide empathetic responses while preventing withdrawal. Phenibut is a GABA-B receptor agonist harm. Our interdisciplinary team examined the and case reports bear resemblance to factors which contributed to improving patient benzodiazepine intoxication and withdrawal and satisfaction then realized a novel, integrated should be regarded as life-threatening. Neither approach was needed to improve patient and staff tianeptine nor phenibut are FDA-approved for use in experience. The Getting Better Together initiative the United States. Urine drug screens do not includes four components: a) Patient Experience, b) commonly assay for these substances. Without Staff Wellness, c) Zero Assaults, and d) Trauma- standardized literature with reliable Informed Care. The team identified and pharmacodynamics, it is difficult to safely anticipate implemented myriad brief interventions for and manage withdrawal symptoms, and given the monitoring and addressing concerns throughout the severity reported in case reports, we recommend admission to form the Patient Experience Initiative. that patients reporting high dose tianeptine and/or A staff training initiative in trauma was instituted phenibut use be monitored for withdrawal in an ICU with changes to the treatment milieu reflecting setting. Conclusion Tianeptine and phenibut are recognition of trauma triggers and planning care to both psychoactive substances available to the public consider this in order to develop a Trauma-Informed without a prescription and both have dangerous and Milieu. Annual training in preventing and managing potentially fatal withdrawal syndromes. crisis situations was augmented by a vision to achieve Zero Assaults by providing regular practice No. 2 situations in which unit teams utilized each other, Getting Better Together: Using Lean Methodology their skills and knowledge of an identified patient in to Develop a Quality Improvement Experience at an impending crisis to de-escalate the situation. While Inner City Hospital education for staff in these techniques is important, Poster Presenter: Farah Herbert, M.D. preventing burnout and fostering strong teams that Co-Authors: Renuka Ananthamoorthy, M.D., share the institutional vision is critical to developing Christine Pyo, Donna Leno-Gordon, R.N., Jennifer a sustained culture change. Wellness Programs were Morrison-Diallo, Ph.D. prioritized and expanded to address staff morale and satisfaction. Follow-up data on the effects of this initiative has shown the following: a) Small but hypothesized mediation model was tested using sustained gains in patient satisfaction scores Preacher and Hayes (2013) Process Macro to obtain measured by Press Ganey, b) Decrease in staff biased corrected 95% CI intervals with 5000 burnout, compassion fatigue and improvements in iterations. The results found that compulsive buying staff perception of workplace support and self-care severity was not a significant predictor of binge through internal survey, c) Strong inverse correlation eating. However, recent advances have found that a between frequency of psychiatric code simulations significant direct relationship is not needed when and injury and assaults, and d) Decrease codes and proposing a significant indirect effect. Indeed, our readmissions for high-profile traumatized clients and results found that the relationship between qualitative data shows a shift in staff perceptions compulsive buying and hoarding was significantly regarding the source of distressing behaviors. mediated by hoarding 95% CI [-.71, -.0002]. Our results suggest that the need to excessively gather No. 3 and store items may be a transdiagnostic process Impulsivity and Its Role on the Relationship that is important in understanding behaviors Between Binge Eating and Compulsive Buying characterized by excessive consumption. Further, Poster Presenter: Cristiana Nicoli de Mattos, M.D. treatments that target the underlying psychological Co-Authors: Hyoun S. Kim, David C. Hodgins, need to hoard items may be an effective treatment Hermano Tavares for both compulsive buying and binge eating.

SUMMARY: No. 4 Compulsive buying disorder is commonly found Suboxone-Induced Bilateral Lower Extremity worldwide and is characterized by excessive Edema: Two Case Reports and Literature Review shopping, which results in distress and impairments Poster Presenter: Shivanshu Shrivastava, M.D. (e.g., financial). Much like other psychiatric Co-Author: Ye-Ming Sun disorders, co-morbidity in compulsive buying disorder is the rule, rather than the exception. SUMMARY: Particularly, the literature suggests that binge eating Background and Objective - Suboxone has been frequently co-occurs in patients with compulsive widely used for opioid detoxification and opioid buying disorder. However, the mechanism by which replacement therapy. Most common side effects of compulsive buying and binge eating are related is Suboxone are nausea, vomiting, back pain, dizziness, unknown. Herein, we present the results of flushing and headache. Very little has been discussed assessing whether hoarding behaviors mediate the in literature about Suboxone leading to peripheral relationship between compulsive buying and binge edema. Here we report two cases of Suboxone eating in a large clinical sample (N=210) of induced edema bilaterally in the lower extremity. compulsive buyers seeking treatment in São Paulo, Methods and Results - The first case was a 44 year Brazil. We hypothesized that the relationship old African American male with a diagnosis of between compulsive buying and eating disorder Schizoaffective Disorder. He was on Suboxone for would be mediated by the psychological need to about a year for opioid replacement therapy. During excessively gather and store items, be it food or his 3rd admission for psychosis, he started items (i.e., hoarding). To this end, patients complaining of bilateral leg pain ( 1-2 out of 10 on voluntarily seeking treatment for their compulsive the pain scale) followed by edema. Cardiac workup buying underwent a semi-structured clinical and venous doppler did not show any abnormality. interview (The MINI) by a registered psychiatrist to He benefited a little from the compression stockings. make diagnoses of psychiatric disorders, including We reduced his Suboxone from 8mg-2mg TID to compulsive buying. Thereafter, they completed a 2mg-0.5 mg BID and then the edema resolved. In the battery of measures to assess the severity of second case, the patient was a 37 year old Caucasian compulsive buying (Compulsive Buying Disorders female with a diagnosis of Bipolar Disorder. She was Scale), binge eating (Binge Eating Scale) and status post below knee amputation and was on hoarding (Saving Inventory Revised). The Percocet for pain at home. She was started on Suboxone to replace her Percocet. Within two days and resources to offer the highest quality care. of starting Suboxone 4mg-1mg BID she complained Currently, over 800 patients with IDD from 58 of bilateral lower extremity edema. Cardiac workup, counties receive mental health treatment through venous and arterial doppler did not show any this statewide grant-funded project. The project abnormality. Complete resolution of edema was fosters innovation and the use of HIPAA protected noted after discontinuation of Suboxone. Discussion software for the provision of the highest quality and Conclusion - There have been reports of mental health care to individuals in the state with peripheral edema with Suboxone use however any the most complex needs. The profound impact of precise data is not available. Website this program led the Psychiatry Residency to create a www.ehealthme.com refers to self reported 267 specialized ID/DD track for its residents. The cases of peripheral edema out of the 6171 Suboxone Division's operations, funding structure, resident users. The exact mechanism leading to edema training curriculum and specialty residency track will remains unknown. There are multiple causes of all be discussed. Here's a preview of the outcomes: • peripheral edema. Mast cell activation with release For individuals engaged in the program, emergency of histamine and tryptase has been proposed as a room visits decreased 96% and hospitalizations possible mechanism. Another suggested hypothesis decreased 86%. • More than 90 individuals were is increased vasopressin release from posterior discharged from state operated institutions and pituitary. The pattern of clinical presentation is not none were readmitted for long term stay saving the well described. From these two cases we learn that state $80,000/person/year. • Travel costs were the peripheral edema due to Suboxone is reversible. reduced up to 68% by not having to travel distances After reducing the dose in the first case and stopping for specialty psychiatric care. Individuals with ID Suboxone in the second case, the peripheral edema experience mental illness at rates higher than that of resolved completely. We also learn that peripheral the general population. There is a lack of physicians edema due to Suboxone is dose dependent as seen with training in ID psychiatry, especially in under- with the first case. Thus for patient's who cannot be served communities. This statewide grant funded taken off of Suboxone completely, reducing the dose program prioritizes patients discharged from state may help. Suboxone can lead to peripheral edema psychiatric hospitals, developmental centers, and after chronic use as well as in acute use as shown by those with multiple emergency department these two cases. visits/hospitalizations due to behavior issues, mental illness, and complex medical needs. The lack of No. 5 appropriate care severely impacts the quality of life Telepsychiatry Webcam Screen Display Preferences for patients with ID in rural areas while also inflating in Individuals With Down Syndrome or Autism in a the cost of care due to increased staffing needs, Community Mental Health Center unnecessary hospitalizations, forced Poster Presenter: Nita V. Bhatt, M.D., M.P.H. institutionalization, and expenses to transport the Co-Authors: Julie P. Gentile, M.D., Allison E. Cowan, person out of the local area for treatment. To Randon Welton complement the clinical projects, the residency training program has just introduced an Intellectual SUMMARY: Disability Specialty educational track offered during Hear from some of the prime architects and years R2 through R4. The panel will take us through clinicians of a thriving Intellectual and the logistics of developing and funding the program, Developmental Disability Division that is committed initial challenges on the road to implementation, to fostering innovation and using technology to available resources, clinical services and training provide cutting edge services to patients with ID/DD components. An interactive format and group in under-served areas. Ohio's Telepsychiatry Project discussion will help determine if Intellectual began in 2012 to provide specialized services to Disability Psychiatry training and utilization of individuals with co-occurring mental illness and Telepsychiatry could be effective educational and intellectual disability with the most complex needs clinical tools for the provision of quality mental living in outlying areas that lack the infrastructure health care for patients with ID and the training of with symptoms of acute psychosis, hypersexual psychiatry residents. behavior, and autonomic instability. He was unable to give any coherent information upon admission No. 6 and was extremely agitated and physically Sugar and "Spice" and Nothing Nice: Comparing the threatening toward staff. He attempted to elope Evaluation and Treatment of K2-Induced Psychosis from the emergency department and required Versus Marijuana-Induced Psychosis mechanical restraints. He was given sedatives and Poster Presenter: Lauren Pengrin, D.O. admitted to the internal medicine floor for further workup. Internal medicine service considered the SUMMARY: differential diagnoses of metabolic encephalopathy, Synthetic cannabinoids refer to a group of substance intoxication, bipolar disorder, and psychoactive chemicals that are infused into dried schizophrenia. The patient was given supportive plant material or as a liquid designed to be used in therapy to address his hypertension, tremor, and vaporizers or e-cigarettes. These chemicals are called agitation. CT imaging of the brain and lumbar cannabinoids because they are related to active puncture were unremarkable. Labs revealed compounds found in the marijuana plant. However, elevated CPK, elevated WBC, and evidence of they may affect the brain much more powerfully dehydration. Urine toxicology screening was than marijuana; their actual effects can be negative. The patient remained quite disorganized, unpredictable and, in some cases, severe or even agitated, and sexually inappropriate the following life-threatening. Many clinicians are now assessing day. Psychiatry was consulted to evaluate the and treating patients who become intoxicated with patient and recommend further treatment. Upon synthetic cannabinoids, often called "K2 or Spice". In evaluation, he was disoriented, verbally aggressive, some areas of the country, physicians may not be and appeared to be responding to internal stimuli. very familiar with the effects of K2. The He was unable to provide and history and no next of presentations differ significantly from the psychosis kin was found to gather collateral information. Given associated with marijuana and are often much more the onset of psychotic symptoms, the Psychiatry difficult to treat. K2 induced psychosis tends to be team ordered specific toxicology labs to test for much more severe and difficult to treat than recent synthetic cannabinoid use, however the marijuana induced psychosis. Patients often require results often take many days to return. The patient treatment with antipsychotic medications and was managed with moderate doses of typical inpatient psychiatric treatment. Marijuana induced antipsychotics and benzodiazepines to address his psychosis is usually self-limiting and does not cause a symptoms of psychosis, hyper-sexuality, and lengthy duration of distress or inpatient agitation. After 4 days, the patient became more hospitalization. I will be presenting various case coherent and was able to provide a limited history. studies in addition to a literature review comparing He admitted to using what he thought to be and contrasting the evaluation and treatment of marijuana, though he stated he had purchased the psychosis induced by K2 versus marijuana. The drug from a different dealer. The patient said that implications of this study will help guide clinicians in the "marijuana" looked and smelled different when their initial evaluation, treatment selections, and he smoked it. He reported having no memory of the follow up care in such cases. previous 5 days, including his presentation in the ED or subsequent transfer to inpatient psychiatry, and No. 7 was ashamed of the actions he had committed Diagnosing and Treating Synthetic Cannabinoid during that time. He made a full recovery and was Intoxication in a Patient With New-Onset Psychosis discharged to the community. Synthetic Poster Presenter: Lauren Pengrin, D.O. cannabinoids are a major problem in Washington DC and are not included in routine toxicology screens. SUMMARY: This case illustrates the difficulty faced by clinicians A patient with a history of Major Depressive in identifying acute intoxication with synthetic Disorder presented to an emergency department cannabinoids as the symptoms often mimic other psychiatric conditions. Standard toxicology screening by the psychiatry consult service and the community does not test for synthetic cannabinoids and specific services board, and was transferred to a different toxicology test results can take days or weeks to institution for inability to care for herself. During return. In this poster presentation, I discuss the that admission she was evaluated for stroke and importance of correct diagnosis and treatment of found to have chronic basal ganglia infarcts and synthetic cannabinoid intoxication and the possible subacute left thalamic stroke. This patient's challenges clinicians face in doing so. stroke symptoms were missed on multiple occasions by multiple evaluators. In addition to the stigma No. 8 associated with a diagnosis of mental illness, active Symptoms of Psychosis Distract From the Chief psychiatric symptoms have the potential to serve as Complaint in a Young Patient With Severe, Chronic a distraction and may activate unconscious biases, Schizoaffective Disorder and Stroke changing the response of caregivers. This case serves Poster Presenter: Erin Dooley as a reminder of the importance of carefully Co-Authors: Eliza Buelt, Gabriela Pachano attending to patients' subjective complaints as well as any and all notable objective findings on physical SUMMARY: examination. This poster reviews the impact of the The patient is a 33 year old black female with a stigma of mental illness on access to optimal history of schizoaffective disorder, bipolar type, type psychiatric and medical diagnosis and treatment. 2 diabetes, hypertension, and chronic kidney disease who presented to the Emergency Department No. 9 complaining of right-sided weakness. In addition, the Everyone Has Trauma Until Proven Otherwise: Our patient was demonstrating symptoms of mania approach in the ER including tangential thought process, bizarre thought Poster Presenter: Lidia Klepacz, M.D. content, and disorganized behaviors including Co-Authors: Sahil Munjal, M.D., Cecilia Asante, singing and attempting to disrobe. She was noted to Felicia Parris, Alex Pelliccione have an abnormal gait but otherwise normal neurological exam. She was evaluated by the SUMMARY: emergency department, the psychiatry consult team, Trauma is the number one cause of death for the community services board, and was "medically Americans between the ages of 1 and 46 years. In cleared" for transfer to another institution for acute the US, rate exceeds 12 other developed countries mania with psychosis. She was treated and and does case a reduction of lifespan in the U.S. Each discharged home after about two weeks. Reportedly year, trauma accounts for 41 million ER visits and 2 during this admission she "refused" MRI. The patient million hospital admissions. We will discuss the returned to the Emergency Department immediately physician's role in treating trauma including following hospital discharge, requesting medications SAMHSA's 4 R's- Realize impact of trauma, Recognize and a wheelchair for her right sided weakness, which signs and symptoms of trauma , Responds to patient was noted on exam. She was given instructions on using trauma informed approach and Resist re- how to get medications, and a wheelchair was traumatization. Our approach- 1. We do an ordered for delivery to her home the next day. She immediate triage prevent re-traumatization and was discharged from the ER without specialty create a trusted environment. Re-traumatization consultation. Later in the same day, she returned to occurs when the patient feels as if he or she is the ER again with continued complaints of right undergoing another trauma. 2. We inform the sided weakness and request for prescribed patient what to expect in the screening process. 3. medications. In the emergency department she Adjustment of tone and volume of speech to suit the became agitated regarding her care and required patient's level of engagement and degree of comfort emergency psychopharmacologic restraint. She was in the interview. 4. Approach the patient in a noted to have right hemiparesis, but was again supportive manner. 5. Elicit only the information "medically cleared" by the emergency team without relevant for determining a history of trauma and evaluation for neurological symptoms. She was seen possible existence of trauma. Give the patient as much personal control as possible during the clients and practitioners recognize one another as assessment. 6. Avoid being judgmental. We will experts and collaborate in setting treatment goals, discuss the principles of patient centered care which discussing treatment options, and deciding together have led our rates of restraints being 0.1% in the ER. on a treatment plan. Although SDM is considered an We will also discuss the six core principles of essential component of recovery oriented Trauma-Informed Approach including Safety, psychiatric practice most mental health centers Trustworthiness and Transparency, Peer Support, report challenges to implementing SDM in their Collaboration and Mutuality, Empowerment, Voice regular services. Objectives: To design and and Choice & Cultural, Historical and Gender issues implement a SDM program in a community mental health center, and to measure SDM utilization, No. 10 quality of life, medication adherence and decision Psychiatric ER as a “Heart and Soul” of Psychiatry: conflict among clients with severe mental illness How to Reduce Restraints/Seclusions in the ER (SMI). Methods: Psychiatric rehabilitation staffs Poster Presenter: Lidia Klepacz, M.D. (n=15) including nurses, recovery facilitators, and Co-Author: Sahil Munjal, M.D. peer support workers participate in ongoing training and supervision in SDM. Training covers the SUMMARY: importance of relationships, empowerment, skills The psychiatric emergency room is the major point training, education, and decision aides. Psychiatric of entry to acute psychiatric services for persons rehabilitation staffs utilize SDM concepts and with severe mental illness, particularly those who knowledge while serving people with SMI, and help are violent. The rates of restraint/seclusion in the them prepare for the briefer visit with their psychiatric emergency rooms range from 8 to 24%. psychiatrists. People with SMI are encouraged to In our opinion, patient centered care and other share their preferences and opinions about their specific strategies can significantly reduce the treatment, articulate requests, and engage in a incidence of restraints which is corroborated by our conversation with the psychiatrist in order to come incidence of restraints as 0.1% of the total visits to to a decision. Psychiatrists also regularly use SDM the psychiatric emergency room. Our approach concepts during the brief visits. This is a longitudinal includes the following- 1. Early triage 2. Patient natural outcome study where clients with severe centered care 3. Assess for medical and psychiatric mental illness receiving community based flexible emergencies. 4. Evaluate patients in crisis 5. support services with capacity to make medical Evaluate, treat and reassess patients 6. Identify decision are eligible to participate. The research stressors, challenges, 7. Identify the strengths 8. protocol was approved by institutional review board Coordinate care and services in the community for at Berkshire Medical Center. We collect monthly patients with mental illness 9. Assessing the risk of data on the utilization of SDM as subjectively violence against self or others. We, through this reported by psychiatrists and rehabilitation staffs. poster will explain the various strategies that we use Data on quality of life, medication adherence, and to make out ER safer for our patient and our staff. decision conflict are collected using validated questionnaires every 6 months. Results: Out of 44 No. 11 people with SMI enrolled in the longitudinal study, 2 Share and Share Alike: Integrating Shared Decision died of natural causes and 42 were included in the Making Into Community Mental Health analysis. Thirty four (81%) clients had average of at Poster Presenter: Shreedhar Paudel, M.D., M.P.H. least 1 SDM visit per month and 13 (31%) had Co-Authors: Jesse Robillard, M.D., Oliver average of 1 SDM visit per week with psychiatric Freudenreich, M.D., Rabin Dahal, M.D., Melinda rehabilitation staffs. Similarly, 26 (62%) of them had Randall, M.D. average of at least 1 SDM visit every 2 months and 13 (31%) had average of at least 1 SDM visit per SUMMARY: month with psychiatrists. Conclusion: SDM can be Introduction: Shared Decision Making (SDM) implemented for people with SMI in a community emphasizes an interactive process where both mental health center. Psychiatric rehabilitation staffs can fulfill a critical role in supporting decision making use, history of incarceration, and/or poor primary around treatment, but this needs to be further social support. This subset of patients tend to utilize defined. Analysis of correlation between SDM a significant amount of limited clinical resources and utilization and quality of life, medication adherence, may play part in increasing waiting times in the ED. and decisional conflict needs to be completed. Cases such as these, with patient refractory to engagement, have intensified the debate of No. 12 developing targeting programming toward this Engagement of Ultra-High Utilizer in the Psychiatric population subset. Hospitals with such a population Emergency Service may benefit from partially reducing the cost of Poster Presenter: Sina Shah-Hosseini, M.D., M.S.E. services. Small steps in identification of these Co-Author: Raj Addepalli subsets of ultra-high utilizers and engagement of these patients can result in significant cost savings. SUMMARY: Previous studies have documented efforts in Lincoln Hospital is part of the Health and Hospital reducing the cost associated with the ED visits of Corporation which serves the poorest congressional these ultra-high utilizers. However, creative district in the United States and is among the busiest strategies such as designating a small part of the emergency rooms in the country averaging Emergency Department as a safe haven for these approximately 170,000 visits per year. We present patients and as non-treatment areas with some the case of a 42 year old man, with over 600 clinical oversight as needed may help in reducing the emergency department visits complaining of various cost. It would also make available resources for psychiatric symptoms, including symptoms patients who need more acute attention. suggestive of substance induced psychosis, substance induced depression, self-reported No. 13 symptoms of depression which clear up in less than Adverse Childhood Experience as Predictors of 12 hours, and self-injurious behaviors such as Nicotine, Alcohol, and Drug Use among Patients cutting, overdose of medications and conditional with Serious Mental Illnesses suicidal ideation. Despite intensive efforts to engage Poster Presenter: Simone Anderson, M.Ed., B.S. the patient in outpatient mental health services, Lead Author: Luca Pauselli substance use rehabilitation, and housing services, Co-Authors: Samantha Ellis, Michael T. Compton, the patient has consistently refused or failed to M.D., M.P.H. follow-up with referrals. The patient has reported repeatedly that he refuses city shelter services SUMMARY: because they are too unsafe, and has engaged in a Background: The association between adverse recurring pattern of using the Emergency childhood experiences (ACEs) and the use of Department as a place to sleep overnight, and nicotine, alcohol, and other drugs has been widely subsequently requesting discharge in the morning. studied and proven in the general population. This patient has been deemed to be an ultra-high Cigarette smoking, along with other forms of utilizer of the Psychiatric Emergency Service, with substance dependence, represent a common co- continuous cycle of requesting care, and then occurrence among those with serious mental refusing when needs are met. This case illnesses (SMI). Few studies have focused on the demonstrates that current psychiatric and substance association between ACEs and cigarette smoking, use treatments do not meet the needs of this alcohol use, and drug abuse in individuals with SMI. patient, and is part of a significant subset of patients Methods: 143 inpatients with serious mental who demonstrate similar behavior. Previous illnesses were recruited to take part in a larger retrospective studies have shown that high utilizers study. From an in-depth, approximately 4-hour tend to be homeless, have a developmental delay, assessment, we gathered information on have personality disorders, history of inpatient sociodemographic variables, diagnosis, the Patient psychiatric admissions, uncooperative with Health Questionnaire-9 (PHQ-9), the Adverse treatment recommendations, history of substance Childhood Experiences scale (ACE), the Fagerström Test for Nicotine Dependence (FTND), the Michigan Alcohol Screening Test (MAST), and the Drug Abuse SUMMARY: Screening Test (DAST) to investigate the relationship The Great Lakes Region of Africa, specifically between ACEs and nicotine, alcohol, and drug abuse. Rwanda, The Democratic Republic of Congo, and Results: The sample mean age was 33.9±12.0 years, Burundi have endured years of conflict, which 61.5% were males, 53.1% were African American, heightened with the genocide taking place in 1994 and 74.1% had a psychotic disorder. We found between the Hutus and Tutsis. During that time, modest positive correlations between ACE total estimates of up to 1 million Rwandese were killed score and FTND (?=0.22), MAST (?=0.23), and DAST and many were displaced. Studies at the time (?=0.25) in the overall sample. We re-ran the estimated that 94% of people in Rwanda Spearman's correlations by gender, and found that experienced at least one genocide event (witnessing females showed a stronger correlation between ACE murder of family members, having property or and FTDN than males (0.30 vs 0.16), while males had homes destroyed, and having lives threatened). stronger associations between ACE and MAST (0.27 Children became soldiers and women were raped. vs 0.16), and DAST (0.33 vs 0.11) compared to HIV became a weapon of war across the region. females. We then dichotomized FTND, MAST and Studies began to emerge soon after demonstrating DAST scores and ran Student's t-tests on the mean high prevalence rates of PTSD, depression, and ACE score in males and females based on substance prolonged grief. The fighting continues in many parts use status. Women who smoke had a statistically of the region to this day, which continues to amplify significant higher ACE score compared to those who pathological trauma symptoms. A review of the did not (5.7±2.7 vs 4.1±2.5), while for men, literature examines what we know about the post statistically significant higher mean ACE scores were traumatic symptoms that remain amongst this observed for alcohol users (5.8±2.6 vs 4.3±2.9) and population and also highlights the resilience that drug users (5.8±2.7 vs 3.9±2.7). Conclusion: The victims and perpetrators alike have demonstrated. In mental health system has been grappling with multiple studies examining this population, rates of effective approaches to cigarette smoking, alcohol PTSD were found in up to 75% and rates up use, and drug abuse among individuals with SMI. depression up to 77% of people. Based on these These behaviors, along with many other factors, results, nearly a quarter of a century later, evidence drive a reduction in life expectancy of over 20 years exists that post traumatic symptoms remain higher for this population. Our study suggests that ACEs in the Great Lakes Region than in many other parts may contribute to these lifespan-shortening of the world. There is much to learn about trauma problems; furthermore, differential patterns of and resilience from this area of the world which has association between ACEs and adverse health endured such a horrific past. behaviors exist in men and women. Further research would be useful in this direction since, if confirmed, No. 16 these findings should drive not only preventive Posttraumatic Stress Disorder in Pediatric policies for childhood exposure to adverse events Populations but also strategies on trauma-informed care so that Poster Presenter: Nusrat Jahan, M.D., M.B.B.S., early traumatic events will have lesser lifelong M.P.H. impact on patients with SMI. Co-Authors: Muhammad Annas Tahir, M.D., M.B.B.S., Mehtab Rana, M.D., M.B.B.S., Humaira No. 14 Masoud, M.D., M.B.B.S. WITHDRAWN SUMMARY: No. 15 Objective: Posttraumatic stress disorder (PTSD) due The Lingering Trauma and the Impressive Resilience to its nonspecific presentation in children becomes in the War-Torn Great Lakes Region of Africa difficult to diagnose. The main objective of this case Poster Presenter: Kaitlin M. Slaven, M.D. report is to diagnose and manage the PTSD Co-Author: SuZan J. Song, M.D., Ph.D., M.P.H. symptoms in the pediatric population. Case: 6 Years Old child with past h/o Pfeiffer Syndrome, attention needs to diagnose it. Repeated surgical procedures deficit hyperactivity disorder (ADHD), and obsessive- for any congenital anomaly or syndrome can be a compulsive disorder (OCD) was brought to the crisis risk factor for pediatric PTSD. It is very important for center with reports of worsening aggression and healthcare professionals to be aware of the behavioral outbursts that had caused the patient to comorbidities and nonspecific presentation of PSTD be picking at his sutures leading to dehiscence of the before starting management. suture sites. The Patient had sleep problems, increased arousal, hypervigilance, and behavioral No. 17 reenactment. The Patient's mother reported the Social Isolation Leads to Suicidal Ideation Through a patient loses control quite often and there had been Path of Impaired Sense of Self multiple episodes of such behavior since the age of 3 Poster Presenter: Firouz Ardalan, B.A. years. The Patient had 3 surgeries in the past (at the ages of 2, 3, and 6 years) for the cranial stenosis SUMMARY: syndrome. The Patient was diagnosed with ADHD Background: There is general consensus amongst and OCD due to his behavioral symptoms and he has current and previous research that both shame and started on the stimulants and selective serotonin social isolation play a role in suicidality. However, reuptake inhibitor (SSRI) 6 months ago. There was research suggests that shame's role in suicidal no significant improvement in his symptoms. The behavior may vary across different populations. child was aggressive and did not engage well with Nonetheless, there is a need for more research on the mental status and physical examination. how shame or sense of defectiveness is related to Discussion: The symptoms of PTSD can be subtle and suicidal risk. This present study tests a path model may resemble those of other psychiatric and that social isolation leads to a sense of defectiveness behavioral disorders. Children who have experienced and shame, which in turn leads to increased suicidal trauma may exhibit sleep difficulties (frequent risk. Method: Seventy-seven (77) patients were awakenings and nightmares), flashbacks, irritability selected from a larger study on the inter- or angry outbursts, trouble concentrating, the relationships of various aspects of psychopathology. behavioral reenactment of the trauma, anxiety, All subjects were recruited from an inpatient phobias, and social avoidance. PTSD requires that psychiatric unit in a large urban hospital. Data was symptoms persist for more than 1month. The collected and analyzed from two self-report undiagnosed cases of PTSD in children predispose measures and one clinical interview. The scales used them to other psychiatric complications e.g. major were the Young Schema Questionnaire (YSQ-S3), the depressive disorder, aggression, substance use, Interpersonal Support Evaluation List (ISEL-SF) suicidal thoughts and suicidal attempts. There are no Appraisal, Belonging and Tangible subscales, and the specific laboratory tests for PTSD. Several Columbia Suicide Severity Rating Scale (CSSRS). Path psychometric measures, e.g. semistructured analysis was conducted with CSSRS lifetime suicide interviews or self-report measures are used to ideation as the dependent variable, YSQ-S3 evaluate PTSD in children. Child PTSD Symptom Scale defectiveness/shame as the mediating variable, and (CPSS) is an effective scale with the sensitivity of 84% the three ISEL-SF subscales and YSQ-S3 social and specificity of 72%1. Trauma-focused cognitive- isolation as the independent variables. Results: Our behavioral therapy (TF-CBT) is the first-line results support a model with a path from both ISEL treatment for PTSD. SSRIs are not FDA-approved for Appraisal (Beta = -.224, p=.028) and YSQ-S3 Social the treatment of PTSD in children. Sometimes Isolation (Beta = .640, p<.001) to YSQ-S3 symptoms of ADHD may mimic the PTSD. Stimulants Defectiveness/Unloveability. In turn, we found a have excellent results for ADHD adolescents and path from YSQ-S3 Defectiveness/Unloveability to good results for children. If stimulant is not CSSRS Suicidal Ideation (Beta= .515, p=.004). There improving the symptoms of ADHD, then the health was no direct effect of YSQ Social Isolation or ISEL care professionals should re-evaluate the patient for Appraisal on CSSRS Suicidal Ideation. There were no another diagnosis. Conclusion: Pediatric's PTSD may significant paths from the ISEL Belonging or Tangible mimic any psychiatric illness, and low threshold subscales. Discussion: Our results support prior research showing a relationship between lack of PSP lead to recovery outcomes. A chief category, social support, impaired sense of self and suicidal "Functioning and Reprieve," emerged as the risk. Specifically, it appears that reduced social foundation of our model, since it clarified what support has a direct effect on sense of self, which in components of recovery participants seek via the turn directly impacts suicidal ideation. Indeed our PSP. This finding indicates that out-patient peer data suggests that the effect of social support on support focuses on improving participants' suicidal ideation is fully mediated by sense of self as functioning in society and fostering participants' defective. This highlights the importance of ability to manage difficult emotions. Our enhancing social support as prevention against subcategories—experiences of comfort, suicidal risk. camaraderie, and exposure that produce recovery orientation and connectivity outcomes—describe No. 18 the mechanisms underlying PSP-mediated recovery. Peer Support in an Outpatient Program for Overall, these findings can help optimize outpatient Veterans With Posttraumatic Stress Disorder: PTSD peer support programs. They suggest Translating Participant Experiences Into a Recovery reorienting the training of the certified peer Model specialists to emphasize functioning and reprieve Poster Presenter: Anusha Kumar, B.S. outcomes rather than specific approaches. They can Co-Authors: Kathryn Azevedo, Ph.D., Jeremy Ramirez, also communicate to traditional mental health M.P.H., Elon Hailu, B.A., Adam Factor, B.A., Steven providers what elements of PTSD recovery the PSP Lindley, M.D., Ph.D., Shaili Jain, M.D. uniquely contributes to, which would advance integration of the PSP into the existing VA mental SUMMARY: health care framework. Finally, they identify Veterans returning from recent conflicts in functional outcome measures (level of social Afghanistan and Iraq present with increased rates of support, perceptions of empowerment, quality of post-traumatic stress disorder (PTSD), while veterans life markers, employment status, etc.) rather than from prior service eras continue to seek trauma- clinical measures as the most appropriate for based services. Peer support for veterans with PTSD upcoming evaluations on the efficacy of PTSD peer has the potential to resolve ongoing challenges in support. veteran access and engagement in mental health care. Assessing the value of peer support services No. 19 requires a thorough understanding of the expected Intrapersonal Theory of Sudden Suicidal Tendencies role and the empirical mechanisms of peer support Poster Presenter: Muhammad Annas Tahir, M.D., participation in PTSD recovery. To address the M.B.B.S. current dearth of in-depth qualitative data on these Co-Authors: Nusrat Jahan, M.D., M.B.B.S., M.P.H., topics, this study interviewed participants from an Zara Muzaffar, Tauqeer Tariq established outpatient PTSD program, the Peer Support Program (PSP), located in the remote SUMMARY: satellite clinics of the VA Palo Alto Health Care Suicidal behavior has been studied in great detail in System in Northern California. After obtaining IRB context of psychiatric disorders and socioeconomic approval, 29 PSP veteran participants were stressors. Can a person with no history of psychiatric interviewed. A domain analysis of 300 plus pages of disorder and no or very mild psychosocial stressor narrative transcripts generated 24 codes through a claim his life; is a question that is still unanswered. grounded theory method. Codes were organized into Whenever a bio-psychosocially healthy person the following thematic categories: the role of the commits suicide, a lot of conspiracy theories surface, PSP, positive experiences of the PSP, outcomes of which are sometimes very farfetched. This theory the PSP, and limitations. These results were further proposes the possible psychological underpinnings synthesized into a theoretical model that 1) defines of sudden suicidal tendencies in healthy population the role of PSP participation in PTSD recovery and 2) and with very low magnitude of distress. Human identifies mechanisms by which experiences in the beings can acquire pathologies by either extrinsic factors (e.g. microorganisms, unhealthy lifestyle, increased risk for suicidal behavior. The high psychological or physical trauma) or intrinsic factors; frequency of malingering and antisocial personality where our bodies own systems, genes, enzymes are can cloud suicidality. Timely assessment of new malfunctioning. All present theories of suicide are arrestees, early detection of suicide risk factors, and centralized around these two factors: extrinsic proper management significantly reduce suicide risk (psychosocial stressors) and intrinsic (genetic in inmates. This study was performed to delineate inheritance, chemical imbalance of the frequency of mental illness and substance abuse neurotransmitters). Autoimmunity, where body among arrestees at the St. Tammany Parish Jail defense system attacks its own body is an important (STPJ) in Covington, Louisiana. This information was cause of number of physical diseases. Just like utilized to risk stratify arrestees as to their risk for physical immune system, our mind has psychological self-harm using a Psychiatric Risk Index (PRI) defense system, called the defense mechanisms. classification system. The three main aspects of the Another one is concept of death reversibility (CODR); study were to identify arrestees at risk for life- in which a child till age 6 to 7 years thinks that death threatening withdrawal from abused substances, is reversible, has no fear of death and he is also determine how rapidly patients should be seen by a having imaginary friends. According to this theory mental health professional, and provide a safe healthy people who commit suicide, they land back environment for high risk inmates. 7756 inmates to the stage when a child thinks that death is were evaluated in 2015 and pre-screened for reversible via a defense mechanism called medical and mental health problems immediately regression. Cause of regression could be sudden low upon arrival. Medical, psychiatric, and substance intensity psychosocial stressor. It is a kind of abuse histories, including details about suicidal psychological autoimmunity; a stage of mind that behaviors, were done within six hours of arrest. served its role in the protection during childhood, Urine drug test was performed upon consent. All gets activated at a very high intensity in adults. A arrestees were classified with a PRI score, ranging person with this state of mind will no longer fear the from 1 (very low risk) through 5 (crisis-level). Those death. He may involve himself in dangerous risky categorized as PRI 5 were immediately placed on behavior. Person may commit suicide and or even suicide watch. In 2015, the 1150-bed jail booked an homicide. All this is happening at subconscious level. average of 643 arrestees per month. 20% of This theory shines light on the psychological arrestees reported mental illness; 7% reported a processes through which a normal person may prior suicide attempt; and 1% had active suicidal commit suicide or homicide. What sets apart this thoughts at intake. 55-65% of arrestees were theory from others is it deals with the entirely new actively using drugs; 27.9% were under the influence concept of psychological autoimmunity. of alcohol, and 65-75% of inmates were using drugs and/or alcohol at arrival. 54% of all health care No. 20 appointments were related to mental health. 349 New Approach to Decreased Suicidality Among out of 624 appointments were with the psychiatrist, Arrestees with an average wait of 1 day. An average of 50 Poster Presenter: Sureshkumar H. Bhatt, M.D. inmates reported suicidal thoughts or intent each month and were placed on suicide watch. There SUMMARY: were 3 unsuccessful suicide attempts in 2015. 3 Mental health problems are more prevalent among inmates were restrained from self-harm. There were inmates than in the general population. However, no mental health-related grievances submitted. The there is a limited amount of hard data documenting Bureau of Justice Statistics estimated the 2013 health care in incarcerated populations. Mental national suicide rates in jails to be 46 deaths per illness is particularly difficult to manage in the 100,000 inmates. At the STPJ, there were 3 correction setting as the high-stress environment successful suicides in the last 12 years, which and the loss of individual freedoms can induce amount to 24.5 deaths per 100,000 inmates. Our PRI psychiatric problems and destabilize preexisting system helps jail health staff rapidly identify mental illness; this translates into a dramatically arrestees with unstable mental illness, including those most at risk for suicidal behavior. Using PRI, controlled drug classes were opioids and the jail has reduced inmate suicides to 53% of the benzodiazepines; 2) The most common non- national average. reported medications were dextroamphetamine/amphetamine and No. 21 buprenorphine/naloxone; 3) The majority of patients How Prescription Monitor Program Can Help had multiple prescribers for the same medications; Psychiatric Practice 4) Many patients had been prescribed both Poster Presenter: Sureshkumar H. Bhatt, M.D. stimulants and sedatives; and 5) Stimulant prescription was quite common among patients SUMMARY: diagnosed with bipolar disorder. A prescription It is more difficult for psychiatrists to treat substance monitoring program can be a useful tool, helping abuse and mental health problems when they occur psychiatrists to identify unreported use of concurrently. Abuse of prescription medications is a prescription medications. This can facilitate the serious and growing epidemic in the United States, recognition of substance abuse disorders and and drug overdose has now eclipsed motor vehicle improve the treatment of many mental illnesses that accidents as the leading cause of accidental death in may be exacerbated by prescription drug use. this country. Half of all overdose deaths result from Psychiatrists should make it routine practice to check abuse of prescription drugs, with opioid pain killers a state's PMP before they diagnose a patient or being the chief offenders. Despite increased formulate a treatment plan. awareness of this problem and tighter regulatory control, addicts still find it easy to procure No. 22 prescription drugs for recreational use. The 2013 Treatment of Opioid Use Disorder: Addressing a National Survey on Drug Use and Health revealed Serious Epidemic that the majority of illicitly used pain killers were Poster Presenter: Sahil Munjal, M.D. obtained from medical professionals and not drug dealers. Hidden prescription drug abuse may delay SUMMARY: the diagnosis of other mental health disorders and There has been an escalating opioid crisis in the can significantly complicate the treatment of those country including the lower Hudson Valley as well. conditions. Prescription drug monitoring programs The statistics paint a picture themselves with more (PMP) provide a valuable resource to physicians. than 200 people dead in the Lower Hudson Valley Such programs can help curb the rampant abuse of from pain-pill abuse since 2010 and deaths in prescription drugs, help psychiatrists identify Westchester County have more than doubled from undiagnosed substance abuse disorders, and 21 to 47 per year. A recent letter by the surgeon improve the treatment of other primary psychiatric general has emphasized the need for screening our disorders. This study was conducted in 2016 at the patients for opioid use disorder and to provide or St. Tammany Parish Jail in Covington, Louisiana, in an connect them with evidence-based treatment effort to identify patterns of prescription drug abuse services. We want to improve the knowledge and among selected patients in the jail's Psychiatry Clinic. understanding of these interventions/services Louisiana PMP database was referenced whenever a among our clinicians. We designed and e-mailed a patient reported poly psychotropic therapy or when brief, voluntary, anonymous questionnaire to a patient's reported medication regimen seemed clinicians assessing their knowledge regarding the unusual for the stated diagnosis. The Louisiana PMP evidence-based treatment of opioid use disorder. was consulted for 602 patients enrolled in the jail's We then had a grand round presentation on the Psychiatry Clinic. 79.23% of the patients (n=477) various evidence-based medication assisted were male and 20.76% (n=125) were female. 69% of treatment options available to treat opioid use the patients had been prescribed a controlled drug disorder, which includes methadone, buprenorphine that was not reported during the initial Psychiatry and naltrexone. We then followed it up by training Clinic encounter. The following trends were the clinicians on how to assemble and administer observed: 1) The most commonly prescribed naloxone in a patient with opioid overdose. It is essential for the clinicians to be familiar with these disorder, multiple rehabs was brought to adult ER by tools so they can better address this escalating crisis. EMS after he cut his left forearm and flexor tendons with a knife .On evaluation patient , reported that he No. 23 was homeless but living with ex- wife post his recent Assessing Barriers of Clinicians Treating Patients discharge from a rehab . Yesterday, patient relapsed With Tobacco Use Disorder on alcohol and ex-wife asked got upset and asked Poster Presenter: Sahil Munjal, M.D. him to leave her house. Patient got frustrated and Co-Author: Rachel Zinns, M.D. left his ex-wife's house went to the woods and cut his left forearm with a sheath knife. He had also SUMMARY: been non-compliant with his medications for Tobacco use is very common among patients with approximately 2 years as he felt they weren't helping psychiatric disorders and does account for highest- him. Psychiatry was consulted to evaluate for ranking cause of death in this population. Yet, suicidality. Upon evaluation, patient was found to smoking by patients continues to be an afterthought have no remorse about his actions and lacked insight for most psychiatrists and behavioral health into his actions. He was guarded and upon further professionals. Nicotine dependence (now tobacco evaluation was considered a threat to self and use disorder) has been included in the DSM since others and he met the criteria for inpatient 1980, yet it may be the only substance use disorder psychiatric evaluation. Upon transfer to psychiatric that is not routinely diagnosed and treated in mental ER, patient was belligerent, agitated and irritated. He health settings. The 2008 update to the US Public was angry and wanted to leave AMA. He was Health Service Clinical Practice Guideline for Treating evaluated again by the ER attending and met the Tobacco Use and Dependence recommends that criteria of inpatient psychiatric admission as clinicians and health care delivery systems evidenced by his serious self- injurious behavior, consistently identify and document tobacco use impulsivity, mood swings, depression a, low status and treat every tobacco user seen in a health frustration tolerance and violent threatening care setting. This QI project was undertaken to behavior. Verbal and behavioral intervention was assess and remove barriers in treating patients with used but patient didn't respond. He was offered oral tobacco use disorder in our outpatient setting. We medications to calm down but he refused. For the will report on a survey conducted to assess the sake of safety of patient and others a code grey was attitudes, perceived barriers & knowledge base of called. The code went on for more than 1 hour and our clinicians as well as a chart review conducted about 10 or more staff members were involved. Staff both to assess the prevalence of tobacco use members felt really strong feelings- fear, anxiety etc. disorder in our clinics and to establish a baseline of post this code grey. This led to the concern of our current practices. We will describe a series of awareness regarding code grey - different types, didactic sessions educating the clinicians regarding risks factors involved and ways to premeditate it. the FDA recommended treatment strategies and the Code Grey seems to be psychiatric equivalent of various toolkits available to treat patients with code blue. Code grey is not only as important as tobacco use disorder. We will then report on code blue but in fact can be more dangerous .A outcomes in screening and treatments offered at violent patient can not only be a threat to self but to specific time points after the educational sessions. others- staff and patients as well. A lot of money - in terms of manpower, disability from code grey gone No. 24 wrong and medications gets spent on the code Code Grey: What We Learned So Far! greys. It can also lead to trauma for the staff as well Poster Presenter: Jasra Ali Bhat as the patient. A way to reduce it will not only save Co-Authors: Lidia Klepacz, M.D., Lidia Klepacz, M.D. expenses but also save patient and staff from trauma. If one could anticipate code greys from the SUMMARY: first look of the patient, a lot of money, time and bad Mr.X, a 49 year old Caucasian male with past experience can be diverted. In this presentation, we psychiatric history of bipolar-I disorder, alcohol use aim to educate the trainees about the types of code grey, risk factors involved, treatment dogma, early Poster Presenter: Judith Katz, M.D. recognition of code grey and the ways to reduce it. Co-Authors: Aaron Brinen, Psy.D., Ashley Un, M.D., Irene Hurford, M.D., Paul M. Grant, Ph.D. No. 25 WITHDRAWN SUMMARY: The form of psychiatric care that most individuals No. 26 with a schizophrenia spectrum diagnosis receive, at Countertransference Process Group in Residency minimum, is medication management, which makes Training: An Interactive and Personalized Approach these visits a critical part of treatment and a terrific to Study and Explore Psychodynamic Concepts opportunity to promote recovery. Recovery Oriented Poster Presenter: Kathryn Q. Johnson Cognitive Therapy (CT-R) for schizophrenia is an Co-Author: Christian D. Neal, M.D., M.P.A. empirically-supported treatment approach shown to reduce avolition, and positive symptoms. CT-R was SUMMARY: developed to engage even the most symptomatic Psychotherapy training is decreasing, specifically individuals through developing interests and psychodynamic, due to greater emphasis on aspirations and actively pursuing the life of their psychopharmacology. Additionally, trainees often choosing. CT-R involves individualized formulations, find psychodynamic concepts abstract and based on the cognitive model, that guide inaccessible. Psychiatric trainees at Virginia Tech interventions to empower individuals to overcome Carilion School of Medicine organized a monthly barriers to recovery, including positive, disorganized, transference/countertransference process group to and negative symptoms of schizophrenia. Using a CT- explore emotional reactions and examine R framework to guide medication management ambivalence in the therapeutic dyad. All trainee requires a shift in focus of the visit to the individual's levels are included and an attending physician interests and long-term aspirations. This provides facilitates and provides clarification of the context for a discussion of medications. psychodynamic concepts. Transference and Prescribers can then elicit more valuable, reliable, countertransference issues in the clinical encounter and organized clinical data, produce greater are discussed, with the aim of encouraging a adherence to treatment, experience fewer missed psychodynamically-informed approach to patient appointments, and increase interest in supporting care. Readings are assigned and members are services (e.g., labs, case management). We present encouraged to bring clinical material to discuss. This practical steps for integrating the techniques and informal and personal group approach fosters self- principles of CT-R within medication management reflection and provides an opportunity for "self- visits. The 10 pearls include tips for activating analysis". It also promotes understanding and patients even within a short medication awareness of complex emotions in the clinical management appointment, structuring the visit to encounter, with delivery of care and in the mind of be maximally effective, identifying key beliefs the psychiatrist. Participating in this group associated with negative symptoms, delusions, encourages trainees to analyze the influence of their hallucinations and thought disorder, designing feelings on treatment decisions and promotes interventions that weaken negative beliefs and attention to physician wellness and improved strengthen positive beliefs, and assigning action patient care. In addition, it decreases the abstract plans in a manner that does not reinforce negative nature of psychodynamic psychiatry in clinical beliefs. practice. No. 28 No. 27 "Home Groups": Combining Peer and Clinical Integrating Recovery Oriented Cognitive Therapy Support at Community Mental Health Centers for Schizophrenia Into the Medication Management Poster Presenter: Thomas Styron, Ph.D. Visit: Ten Pearls for Moving Beyond Symptoms to Co-Author: Sarah Kamens, Ph.D. True Recovery SUMMARY: biases and decision making that disadvantages Community Mental Health Centers (CMHCs) are marginalized populations. Using different learning increasingly recognizing the uniqueness of services modalities, our workshop describes how bias that can be provided by peers, or experts with influences our cognition, how bias operates within personal experiences of illness and recovery. Peers our personal and professional context, and how our provide an invaluable resource by sharing their biases are informed by the history of discrimination stories of recovery, fostering hopes, facilitating within this country. Participants are asked to take an community-based activities, and using personal implicit assumption test of their choice before experience to help clients navigate the mental attending this lecture, to make conscious individual health system. Despite the growing peer-support bias and understand how this may impact care. In movement, many clinicians and administrators addition to discussing bias, we outline other key remain unfamiliar with the ways in which peer and sociological concepts such as prejudice, racism, and clinical services can be integrated to improve the privilege. Using historical examples such as the Dred quality and efficiency of services. This poster will Scott case, we discuss how these sociological factors introduce the concept of 'home groups,' which are arise out of the context of legally enforced hybrid, co-facilitated groups that combine peer and discrimination in the United States. Through a group clinical services into one weekly session. Home discussion, we highlight the remnants of groups allow members to receive routine clinical disadvantaging policies that continue to contribute care while benefiting from the validation and social to the institutionally enforced oppression of support of a peer. In addition, home group members vulnerable populations. Then audience members will work together to find collaborative solutions to case pair off for a "speed dating" exercise to delve into management needs. The poster will address recognizing personal examples of privileges that common scenarios that arise in groups that are co- marginalized populations may not have. After facilitated by peers and clinicians; it will also address covering this material, we apply concepts to cases ways in which home groups provide collaborative involving real-life scenarios reflecting the complexity and cost-effective solutions to institutional of interactions with colleagues, patients, and our challenges by enhancing community cohesion and greater medical community. Lastly, we introduce fostering alliances within CMHCs. The poster and encourage participants to outline strategies to presenter will encourage visitors to reflect and ask addressing the role of provider bias. Given the questions about how they might integrate home sensitive nature of this discussion, fewer presenters groups into their existing practice or organization. were chosen who could effectively convey the information and engage the audience. No. 29 Saying Hello to Bias No. 30 Poster Presenter: Ayana Jordan Parachute NYC: What Is the Psychiatrist's Role in a Co-Author: Kali D. Cyrus, M.D., M.P.H. Dialogical, Non-Hierarchical Model? Poster Presenter: David C. Lindy SUMMARY: Co-Authors: Neil Pessin, James Mills, Adam Kaufman, Healthcare disparities arise from a complicated Terrance Roye series of events involving individuals, systems, and the environment at times. While disparities in care SUMMARY: are influenced greatly by structural inequality, we Parachute NYC uses an innovative model to treat must also examine the role of the provider in people experiencing psychotic symptoms which exacerbating the gaps in access, treatment, and blends the psychopharmacologic medical model with outcomes for minority groups. Additionally, the role the dialogically oriented Needs Adapted Treatment of the provider presents itself as a notable topic Model. Parachute's main treatment vehicle is the worth addressing through medical education. For network meeting in which the "patient" and example, there is a growing body of literature members of his/her natural social system (family, examining the link between physicians' implicit partners, friends) and two Parachute staff meet in the home as often as necessary to allow problems reform incentive payments program' (DSRIP) to and solutions to emerge from the evolving dialogue. achieve the triple aim: transform our delivery of care Network meetings are non-hierarchical and non- with innovative integrated care models and improve coercive; all treatment decisions are transparent; all the health of populations while reducing per capita voices equal. This is a significant departure from costs. DSRIP's Health Home Care Coordination model other treatment models for similar populations, e.g., focuses on ensuring success through three clinical ACT. At the same time, psychiatric diagnosis, risk projects: the Health Home at Risk Care Coordination assessment, and psychopharmacologic treatment program to expand access of care coordination are performed and offered as indicated. In parallel to services to higher risk patients who appear on a the treatment model, Parachute teams strive to be trajectory of decreasing health and who are at risk of non-hierarchical and attempt to give equal voice to re-hospitalization for their SMI diagnosis; Care peer specialists, social workers, family therapists, Transitions Critical Time Intervention (CTI) project, a nurses, and psychiatrists or other prescribers. time-limited, evidence-based practice that seeks to Operated by the Visiting Nurse Service of New York's reduce avoidable hospitalizations and ER usage for Community Mental Health Services since 2012, we members with schizophrenia and/or bipolar disorder have learned that implementing this model can be through the facilitation of community integration both challenging and enriching. In this presentation and support, and the evidence based practice we will present perspectives from a Parachute Improving Mood - Providing Access to Collaborative psychiatrist, peer specialist, and team leader to Treatment (IMPACT) model, fully-integrated care in address such questions as: How does this more primary or behavioral health settings to treat mental collaborative approach among team members health conditions such as depression and anxiety, influence the care of Parachute patients and which require systematic follow-up due to their families? How do the members of the team persistence. We will describe the NY State Health experience the shift from top-down, traditional care Home and the DRSIP program in detail, our to a sharing of power across roles? Where does this outcomes and efficacy of these new innovative leave the team psychiatrist? We will also present DSRIP initiatives. Parachute outcome data and discuss the ways in which the blended model contributes to these Friday, October 20, 2017 outcomes. We will actively invite audience participation and encourage audience members to Poster Session 2 bring their own experiences and questions about Parachute NYC. No. 1 When Patients Supplement: A Case of Kava Kava No. 31 Delirium Integration of Healthcare: A Transformative Model Poster Presenter: Shanique Ampiah, M.D. Poster Presenter: David C. Lindy Co-Authors: Kathleen Crapanzano, Venugopal Co-Authors: Mollie Judd, Manisha Vijayaraghavan Vatsavayi

SUMMARY: SUMMARY: As part of Medicaid redesign, New York State is Introduction: Complementary and Alternative transforming the care provided to high cost users of Medicines (CAMs) are attractive to patients because Medicaid, the highest costs being those attributed to of inadequate treatment response to traditional patients with behavioral health diagnoses. One medications, accessibility, affordability and the lure vehicle for this transformation has been the Health of 'natural' remedies. However, the use of CAMs is Home program which integrates care through the not without risk. One such supplement is Kava Kava utilization of improved treatment protocols, care or Piper methysticum, a South Pacific herb coordination, a shared plan of care between all traditionally used for its anxiolytic and medicinal providers and health information technology. NY properties. We present the following case of a State has also implemented the 'delivery system patient admitted for Kava Kava induced delirium. Case Description: Mr. G is a 63 year old Caucasian patients with severe mental illness have a higher male who became delirious after excessive Kava prevalence of diabetes, hypertension, smoking Kava ingestion. Although he was being treated by a related illness and complications due to psychotropic psychiatrist for MDD, GAD, OCD, and benzodiazepine medications side effects. Patient with severe mental use disorder, he had been supplementing his illness may have limited social support, barriers in psychotropic medications with Kava Kava 500 mg accessing health care, and lack of awareness of the BID (capsules or ethanol based liquid formulation). potential medical risk. These untreated medical The recommended maximum daily dose is 120-250 conditions can worsen when a noncompliant mg (Teschke et al, 2013). Over the last year, he psychiatric patient decompensates which leads to increased his intake to several bottles daily. EMS was their hospitalization. When a patient arrives on the called after patient was found on floor in his own psychiatric inpatient service, emphasis is primarily vomitus and with an altered mental status. He was focused initially on stabilization of psychiatric managed on a diazepam taper, with quetiapine, and symptoms and the medical comorbidities can at the resumption of his outpatient medications. At times be overlooked. Therefore, integrating both follow up visit, he had stopped taking Kava Kava and mental and physical health care on the inpatient was seeking substance abuse treatment. However, service can be challenging and can delay adequate within 2 months of discharge, he was taking another and timely medical care. Optimal management CAM supplement in addition to his prescribed demands awareness of these existing and potential medication regimen. Discussion: Despite limited data medical comorbidities starting on the inpatient unit. to support their efficacy, CAM use is on the rise with Treatment plan strategies and guidelines for up to 50% of patients being treated for psychiatric managing medical comorbidities on psychiatric disorders taking supplements (Larzelere et al, 2010). inpatient service will be discussed. Even more concerning is that 79% of patients do not disclose their supplement use to their physicians No. 3 because they consider them to be 'natural' or simply A Critical Intervention at a Critical Time: Providing are not asked (Freeman et al, 2010). However, with Access to Pediatric Mental Health Care Through a no stringent regulation, all kava supplements are not Collaborative Care Model created equally and varying extraction techniques Poster Presenter: Scott B. Falkowitz, D.O. and levels of kavalactones increase the risk of Co-Authors: Rajvee Vora, Andrew Tucci, Christina D. adverse effects. These include dermopathy (dry, Gerdes, M.D., M.A., Carla Gabris scaling skin), drowsiness, cerebellar dysfunction, movement disorders and vertigo (Sarris et al, 2011), SUMMARY: in addition to an association with hepatotoxicity and Background: At this time, one in five children in the the potential for pharmacokinetic drug interactions United States suffers from some form of mental (Showman et al, 2015). With the allure of illness, with only 20% of these children ever naturopathic medicine on the rise, it is imperative to receiving treatment. Half of all lifetime mental explore patients' use of supplemental medications to illnesses begin by age 14, with early intervention prevent potential harm. providing an opportunity to reduce long-term morbidity. Approximately 75% of children and No. 2 adolescents with psychiatric disorders are seen in Managing Medical Comorbidities on the Inpatient the pediatrician's office, but multiple barriers Psychiatric Unit impede execution of mental health care delivery. Poster Presenter: Jayanta Chowdhury, M.D. There have been increasing efforts to identify Co-Authors: Luisa Gonzalez, Panagiota Korenis, M.D., methods of integrating behavioral health care into Monika Gashi the primary care environment. At present, the collaborative care model has the most robust SUMMARY: research evidence base for improving quality of care, Psychiatric patients have high incidence of medical health outcomes, lowering costs, and increasing comorbidities. Several studies have indicated that satisfaction for both patients and Pediatricians. This project utilized the collaborative care model in a Co-Authors: Omar Galarraga, Ph.D., Ira Wilson, M.D., primary care Pediatric clinic to demonstrate effective M.Sc., Benjamin L. Cook, Ph.D., M.P.H., Amal Trivedi, treatment of mild to moderate depression and M.D., M.P.H. anxiety. This represents a novel implementation of this care delivery model, as the majority of research SUMMARY: to this point has been in adult primary care. Objective.The purpose of this study is to determine Methods: Following the collaborative care model, a the extent to which one state's Health Home behavioral health care manager (BHCM) was initiative impacted access to and utilization of integrated into a primary care clinic five days a week. primary care services for Medicaid beneficiaries with The BHCM assists the primary care provider (PCP) Serious Mental Illness (SMI). Methods. Using Rhode with the identification and treatment of patients Island Medicaid claims (2009-2013), we employed a with behavioral health conditions. The BHCM quasi-experimental difference-in-differences provides a range of services including: patient approach with propensity score weighting to education, short term evidence-based evaluate changes in service use before and after the psychotherapy, monitoring of treatment response, introduction of Health Homes. The predictive and facilitating psychiatric consultation between the margins method was used to predict access and PCP and their supervising psychiatrist. The BHCM utilization for treatment and control groups in the tracks each patient in a HIPAA protected registry and pre- and post-intervention periods. The treatment presents each patient to the consulting psychiatrist. group (N=6,252) were Medicaid beneficiaries ages The BHCM's patient registry was used to monitor 18 to 64 with a diagnosis of SMI (major depressive clinical outcomes including the number of patients disorder, bipolar disorder, or schizophrenia) that seen, office visits, ED diversions, outside behavioral participated in Health Homes. The comparison group health referrals, initiation of psychotropic (N=4,128) possessed similar characteristics as the medications and average change in PHQ9 scores. All treatment group but did not participate in Health the outcome measures reflect collaborative care Homes. Primary outcomes to assess Health Home's provided from September 2016 to November 2016. impact were access to primary care (dichotomous) Results: The BHCM saw a total of 126 patients with a and number of primary care visits (count), overall total of 246 office visits. There were 14 ED and for commonly experienced physical health diversions. The BHCM assisted with 31 outside conditions (chronic obstructive pulmonary disease behavioral health referrals. A total of 20 patients (COPD), cardiovascular disease, diabetes, were started on a psychotropic medication by the hypertension, and obesity). Results. At baseline, PCP with consultation from the psychiatrist. The Health Home and comparison groups were similar average PHQ9 decreased by 9 percent during this on pre-intervention factors. Among Health Home period. Conclusion: Implementation of the participants, the proportion having at least one collaborative care model in this setting was primary care visit increased from 83.3% in the pre- successful at enhancing access to effective evidence- intervention period to 92.0% in the post- based behavioral health treatment, decreasing the intervention period. The concurrent trend for the number of avoidable ED visits, and helping to deliver comparison group was 85.6% to 87.0%, yielding an efficient mental health care to a population in dire adjusted difference-in-difference of 7.3% (95% CI= need of it. 4.6 to 10.0). Similarly, a higher proportion of Health Home participants, relative to the comparison group, No. 4 experienced at least one primary care visit for COPD, WITHDRAWN diabetes, hypertension, and obesity (all p<0.05). No significant differences existed between Health Home No. 5 and comparison groups in having at least one The Impact of Health Homes on Primary Care primary care visit for cardiovascular disease. Among Service Use Among Medicaid Beneficiaries With Health Home participants, the number of primary Serious Mental Illness care visits increased from 722.0/100 person-years in Poster Presenter: Michael Flores, Ph.D., M.P.H. the pre-intervention period to 1,778.6/100 person- years in the post-intervention period. The and investigate this connection further. In this poster concurrent trend for the comparison group was presentation, we aim to present a case for the 795.2/100 person-years to 1,003.1/100 person- importance of including a qualifier for "lack of years, yielding an adjusted difference-in-difference physical exercise" in the DSM-5 and explore the of 848.7/100 person-years (95% CI: 783.0 to 914.6). impact this would likely have on the evaluation and Estimates also suggested Health Home participants treatment of psychiatric illness. A review of the had an increase in the number of primary care visits literature on exercise levels and mental health for COPD, diabetes, and hypertension (all p<0.05), establishes the case for including ICD-10-CM's "Lack relative to the comparison group. No significant of Physical Exercise, Z72.3" in future DSM editions. differences existed between Health Home and comparison groups in the number of primary care No. 7 visits for cardiovascular disease and obesity. Enhancing Access to Effective Psychiatric Care Conclusions. Investment in the integration of Through the Collaborative Care Model primary care into community mental health settings Poster Presenter: Christina D. Gerdes, M.D., M.A. can improve access to and utilization of primary care Co-Authors: Rajvee Vora, Scott B. Falkowitz, D.O., services for individuals with SMI. Andrew Tucci

No. 6 SUMMARY: Missing From the DSM-5: Lack of Physical Exercise In 2015, SAMHSA's National Survey on Drug Use and Poster Presenter: Lauren Pengrin, D.O. Health estimated that 16.1 million adults in the U.S. had at least one major depressive episode in the SUMMARY: past year.1 For multiple different reasons, including It would be difficult to identify a more important lack of access to psychiatric care, primary care etiological agent in medicine, including psychiatry, settings have become the largest provider of mental than "lack of physical exercise." Lack of physical health services in the U.S. Approximately 60 percent exercise has a major role in serious illnesses such as of patients being treated for depression in the U.S. cardiovascular diseases, osteoporosis, and cancer. receive treatment in primary care settings.2 To Lack of physical exercise has a much broader impact address these needs, many primary care providers than many of the other behaviors listed in the DSM- are integrating behavioral health care services into 5. For example; manic behavior, presence of their practices. Currently, the collaborative care delusions, catatonia, substance use, compulsions, model has the most robust research evidence for depersonalization, narcolepsy, are all found in DSM- improving mental health care provided in the 5; but not the behavior of a lack of physical exercise. primary care setting and can significantly improve More than 40% of DSM-5 conditions have an quality of care, health outcomes, lower costs, and etiological agent with a behavioral component, but increase satisfaction for both patients and primary none compare in magnitude to a lack of physical care providers. This project demonstration uses the exercise. This "lack of physical exercise" is ignored by collaborative care model in a primary care clinic to psychiatry even though recognized by the rest of effectively treat mild to moderate depression and medicine. In ICD-9-CM, its code was V69.0. In ICD- anxiety. Methods: Following the collaborative care 10-CM, it is Z72.3. However, there are no codes in model, a behavioral health care manager (BHCM) DSM-5 allowing psychiatrists to include lack of was integrated into a primary care clinic five days a physical exercise when assigning a diagnosis. week. The BHCM assists the primary care provider Currently, more research is being done to further (PCP) with the identification and treatment of explore this link between physical exercise and patients with behavioral health conditions. The psychiatric symptoms. Now more than ever clinicians BHCM provides a range of services including: patient are advocating for increased education for patients education, short term evidence-based regarding the use of exercise as a treatment psychotherapy, monitoring of treatment response, modality for psychiatric symptoms. We will review and facilitating psychiatric consultation between the the literature on exercise levels and mental health PCP and their supervising psychiatrist. The BHCM tracks each patient in a HIPAA protected registry and community. Methods We surveyed residents presents each patient to the consulting psychiatrist. treating patients in the Residency Clinic and The BHCM's patient registry was used to monitor Comprehensive Psychiatric Emergency Program clinical outcomes including the number of patients (n=21) about their knowledge and comfort in seen, office visits, ED diversions, outside behavioral providing community based resource services using health referrals, initiation of psychotropic a 4-point Likert scale. A wiki page was created, medications and average change in PHQ9 scores. All which consisted of information for various resources the outcome measures reflect collaborative care such as low cost psychotherapy clinics, substance provided from September 2016 to December 2016. rehabs, mobile crisis referrals, sliding scale medical Results: The BHCM saw a total of 132 patients with a clinics, shelters, and food pantries that residents total of 313 office visits. There were 24 ED could access quickly and easily to identify useful diversions. The BHCM assisted with 89 outside supports for their patients. The wiki was organized in behavioral health referrals. A total of 45 patients a way that users could identify agencies by location were started on a psychotropic medication by the (i.e. borough), as well as, by categories. There was PCP with consultation from the psychiatrist. The also helpful information to assist with identifying average PHQ9 decreased by 9 percent during this appropriate resources like directions for patient period. Conclusion: The implementation of the referral, insurance requirements, fees charged, and collaborative care model in this primary care clinic if the agency was currently accepting patients. The was successful at enhancing the population's access residents were polled at 6 months after being given to effective evidence-based behavioral health access to the resource page regarding their attitudes treatment and decreasing the number of avoidable and comfort towards providing community based ED visits. In addition, a significant amount of these resources to their patients. Results In the initial patients were started on a psychotropic medication survey, 20% of residents indicated that they felt within the primary care setting under the guidance comfortable with coordinating access to community of a consulting psychiatrist. resources for their patients. Approximately 27% of the resident felt that they could balance the needs No. 8 of their patients with the available community Using a Wiki to Improve Residents’ Competency in resources. Around 26% felt that they knew how to Community-Based Care and Resource Management talk to their patients' about referrals. In the survey Poster Presenter: Christina D. Gerdes, M.D., M.A. completed after having access to the resource page Co-Authors: Patrice Malone, Eileen Kavanagh, M.D., for 6 months, 48% of residents felt comfortable with Melissa Arbuckle coordinating access to community resources for their patients. Approximately 72% of the resident SUMMARY: felt that they could balance the needs of their Background Resource management is an invaluable patients with the available resources and 95% felt skill that encompasses the ability to coordinate that they knew how to talk to their patients' about access to community resources, consider relative referrals. In addition, 86% of residents said the cost of care, and balance the interests of the patient website was user friendly and 90% of residents with resources. Community-based care includes indicated that they would recommend the website recognizing the importance of community mental to their colleagues. Conclusions Using current health resources and being able to coordinate care technology, we created an easily accessible and up- with community programs. Psychiatrists use both of to-date information page for residents to refer to these skills in their daily practice and it is imperative when providing medical, psychological, and social that resident trainees acquire these skills. We resources in the community for their patients which undertook a quality improvement project which facilitated access to care. incorporated the use of a wiki page (an editable website which allows users to collectively manage No. 9 and share information) to help residents effectively Telepsychiatry-Assisted Follow-Up Engagement of refer patients to various resources available in the Treatment Dropout Substance Users Poster Presenter: Raju Bhattarai were suggested to follow up at the OST center and restart the treatment at the earliest convenient date SUMMARY: . The attendance frequency in the following 1 month BACKGROUND Opioid Substitution Treatment (OST) after the tele psychiatry session was assessed and is a harm reduction approach for Intravenous drug analyzed. RESULTS Twenty-eight out of 32 clients users to shift them to oral Buprenorphine or approached the OST center within 3 days of the Methadone. After a period, many of these clients home visit session and 22 clients remained in drop out facing an increased likelihood of relapse. In treatment until 1 month period following the such individuals a comprehensive approach right intervention. Most common reason for leaving the from the beginning of substance use treatment is treatment was logistic problems. Twenty nine clients essential. In India, OST is run by National AIDS were using some form of substance, alcohol being Control Organization (NACO) and due to nationwide the most common; 18 reported to be using their shortage of mental health professionals, integrated substance of choice: heroin. treatment approach is unaccomplished in majority of centers. Existing literature supports the role of No. 10 economic methods such as tele psychiatry to Where They Are: A Web-Based Mapping Tool That facilitate mental health professionals' reaching out Synthesizes Public Datasets for Clinicians to Better to substance using clients. Brief intervention is Understand Patients’ Extra-Clinical Settings useful in substance use population during different Poster Presenter: Walter Mathis, M.D. phases of drug treatment. Given the low psychiatrist/population ratio in India, tele psychiatry SUMMARY: assisted brief intervention could be a viable In recent years, a growing body of literature has alternative for drop out population. By linking the validated the intuitive notion that where one lives psychiatrists to substance users in remote locations, affects one's health. Factors ranging from household tele-psychiatry could enhance treatment adherence income to the age of housing stock have been shown and promote follow up. METHODOLOGY NACO to influence physical or mental well-being -- the counsellor at every OST center regularly visits the social determinants of health. But, clinicians face non adherent clients' homes to report the reasons of major hurdles to incorporating these findings into treatment drop out. Sixty client clients from the OST clinical care. For instance, while enormous amounts program at Gorakhpur, North India, who had of geographically coded socio-economic and built treatment drop out history of preceding 3 months environment data are available online for free, they were contacted through phone. Every week 10 are spread across various federal, state, and local clients were contacted and home visits were made agencies in different formats. Collecting and to 4 willing clients in each week. Altogether, 32 synthesizing these disparate data is beyond the clients consented for meeting over a period of 2 technical and time constraints of most clinicians. months. Meeting was conducted at home in This poster explores a web-based mapping tool that presence of at least one family member as well as on was developed to facilitate exploration of diverse a one to one basis. A 20 minutes session was public data sets to help clinicians better understand conducted by the counsellor. It began with detailing their patients' settings outside the clinic, informing the family about the purpose of the visit followed by their formulations and intervention strategies. obtaining an informed consent. Demographic details were noted and instructions were given for self No. 11 administration of 'Reason for Leaving Treatment Providing Psychiatric Care to a Young Person at a Questionnaire' (RLTQ)'. After this, the facilitator Comprehensive Youth Center in an Urban Setting connected the client to the psychiatrist through the Poster Presenter: Mary Conlon, M.D. medium of a tablet device for one to one brief intervention session. This was followed by closure SUMMARY: which included a group session with client and the Ms. S., a 23-year-old African-American female, family members to address their queries. Clients comes to a comprehensive youth center to enroll in a college readiness program. She has a high school underutilize and often are apprehensive when degree, currently lives with her mother, and accessing mental health services. As a result, a received special education services in the past but significant number of children with behavioral health no prior mental health treatment. Soon after she issues go without diagnosis and treatment; starts the program, she becomes very attached to frequently leading to potentially negative outcomes. the main teacher. There are concerns about her The UCLA -Kern Medical, Child and Adolescent ability to maintain appropriate boundaries and Ms. Fellowship Program has identified these alarming S. is referred for counseling at the youth center. It is trends and initiated a grassroots community then discovered that she has a history of sexual academic partnership educational campaign focusing abuse by her brother with significant depressive, on educating community members. The research anxiety, and Post-Traumatic Stress Disorder study will provide mental health education symptoms. She is referred to the psychiatrist for promoting stigma reduction, clarifications of mental medication management and ongoing therapy. She health misconceptions and instilling positive responds incredibly well to treatment with an SSRI attitudes toward children's mental health issues. and cognitive behavioral therapy. She is able to Methods: A pilot study will be carried out at several maintain appropriate boundaries with staff community centers in Kern County, with a members, has resolution of her depressive population made up of greater than 52% Latino. The symptoms, is able to work increased hours, and study population will be volunteer community enter a romantic relationship. She reflects back on members interested in learning about children's prior depressive episode in high school and how mental health. They will be provided two separate earlier treatment would have perhaps changed some educational lectures focusing on attention of her trajectory. She is thankful for the current deficit/hyperactivity disorder and depression. treatment and is hopeful about her future as she Literacy scales will be used in a pre and post survey contemplates various job programs and returning to to assess general mental health knowledge, school. Comprehensive youth centers that offer a stigmatizing attitudes, locating mental health wide variety of services including health care, referral information, treatment modalities, education, mental health treatment, career recognition of common mental health conditions in development, recreational activities, and job children, and knowledge about children's mental support, all for free and completely confidential are health well-being. At the completion of data unique places that can meet the needs of many gathering, the study will incorporate final data youth, particularly those that may be collection and statistical analysis to determine disenfranchised and have little other supports. They possible correlations. This time frame will be in line are also excellent places to provide mental health with the American Psychiatric Association SAMHSA care and psychiatric services as they draw young Minority Fellowship (July 2016-June 2018). Results: people that are in need of care but perhaps would The pilot study's primary focus is to increase the not seek it elsewhere. The additional services they communities knowledge concerning children's offer also supplement the more traditional mental health. The use of a community academic counseling and psychiatric services to best serve the partnership will aim to reduce stigmatizing attitudes, needs of the entire young person and their health allow participants to become informed members of and well-being. their community and recognize common mental health conditions in the child population. We No. 12 anticipate that during the course of the study A Grassroots Approach to Mental Health participants will learn how to access mental health Community Engagement and Education services, become familiar with different treatment Poster Presenter: Carlos Fernandez modalities and develop an increase awareness for children's mental health conditions. Conclusions: SUMMARY: Reducing mental health barriers and eliminating Background: Reducing disparities in mental health disparities is crucial in empowering patients and has become a national priority. Minority groups families. By utilizing a community academic partnership model, the objective of the study is to and PTSD symptoms such as anxiety and depression. inform community members about children's mental The subjects' social experiences were also assessed health conditions, reduce stigmatizing attitudes in by asking about engagement in hobbies and school under resourced communities, and increase clubs and interest groups. Results: We will use SPSS community mental health literacy. The UCLA -Kern to generate logistic and multiple regressions and Medical, Child and Adolescent Fellowship Program, assess the degree to which engagement with a social intends to help identify early signs and symptoms of network influences adolescent alcohol use and PTSD mental health conditions for early prevention, symptoms. Based on existing literature, it is intervention and treatment of children within Kern anticipated that an increased level of social County. engagement will be inversely correlated with PTSD and alcohol use. These findings will describe critical No. 13 insight by assessing the value of socially-oriented Protective Effects of Social Support Networks mental health services in communities subjected to Against Posttraumatic Stress Disorder and Alcohol severe stressors or major disasters. Abuse Following Disaster Exposure Poster Presenter: Robert Fuchs No. 14 Co-Authors: Howard J. Osofsky, M.D., Ph.D., Tonya Work Motivation Among Mental Health Nurses in a Hansel, Joy D. Osofsky, Ph.D. Public Psychiatric Hospital in Lagos, Nigeria Poster Presenter: Abosede Adekeji Adegbohun, SUMMARY: M.B.B.S. Background: Many adolescents in New Orleans have Co-Authors: Increase I. Adeosun, M.B.B.S., Richard had repeated exposure to major disasters due to the Ademola Adebayo, M.B.Ch.B. devastating effects of Hurricane Katrina (HK) in 2005 and the Deepwater Horizon Oil Spill (OS) in 2010. SUMMARY: Each of these occurrences have elicited symptoms There is a growing body of literature that has related to posttraumatic stress disorder (PTSD), attributed the quality of services rendered by health depression, generalized anxiety disorder, and personnel to the degree of their work motivation. alcohol abuse. The symptoms of these disorders There is however dearth of information on the have persisted more than ten years after the first of extent of work motivation of mental health nurses in these two disasters took place, reflecting the strong Sub-Saharan Africa. This study assessed the level of influence that HK and OS have had on the Louisiana work motivation among this cadre of workforce population. Our group previously examined the working in a public psychiatric hospital in Nigeria. relationship between the severity of exposure to The factors contributory to their level of work these events and the degree of alcohol use and PTSD motivation were also assessed. Methods: The study symptoms, and we found that children who were was conducted among mental health nurses of the more directly exposed to these disasters developed Federal Neuropsychiatric Hospital Yaba, Lagos, more severe alcohol abuse and PTSD symptoms Nigeria. The level of work motivation and the factors during adolescents relative to children who had less contributory to the work motivation of 86 mental disaster exposure. Despite this important finding, health nurses were assessed over a three-month the protective effects of social support systems such period. Data were analyzed using IBM-SPSS version as family intimacy and engagement in extracurricular 20. Results: The mean age of the participants was activities have not been investigated. Methods: High 39.90 (±8.66) years. Majority of them were females schools in southeastern Louisiana's Saint Bernard (73.3%), married (86.0%) while more than half (57%) Parish administered a survey, the LSUHSC belonged to the senior cadre of nursing. About Department of Psychiatry Disaster Interview, to 54.7% of the mental health nurses were motivated students who had experienced both HK and OS as with their job. The participants' scores on the children. Data were analyzed from over 400 motivation scale ranged from 81 to 119 with a mean adolescents aged 14-18. The questions on the survey score of 98.71±7.94. The highest mean scores were asked for self-report data on the level of alcohol use recorded on the job characteristics and career development subscales while the lowest mean score overall quality of care 8.40 ±1.63. About 73% of the was recorded on the recognition subscale. At least a respondents adjudged the quality of services B.SC degree in nursing was a strong motivational received as good. Participants that had lower level of factor among the study participants. Conclusions: education were more likely to perceive the quality of The findings from this study support previous care received as good. Eight out of ten (80%) of the findings. There is need to strengthen management respondents admitted that they will recommend the capacities in mental health services in Nigeria with service to a family or friend should the need arise. the aim of increasing the work motivation of mental Keywords: Quality of Service, Level of Satisfaction, health nurses in public settings. Keywords: Work Outpatients, Hospital setting motivation, motivational factor, mental health nurses, public psychiatric hospital No. 16 WITHDRAWN No. 15 Perception of the Quality of Service and Level of No. 17 Satisfaction Among Outpatients in a Psychiatric How Are People With Mental Illness Portrayed on Hospital Setting TV Crime Shows? Poster Presenter: Gbonjubola Omorinsola Babalola, Poster Presenter: Jessica Berthelot, M.D. M.M.P., M.B.B.S. Lead Author: Kathleen Crapanzano Co-Authors: Abosede Adekeji Adegbohun, M.B.B.S., Co-Authors: Rebecca Horn, Richard Vath, M.A., Oyewale Alfred Ogunlowo, M.B.B.S., Suraju Margaret Mitchell, M.B.A. Adeyemo, M.B.B.S., Adebayo O. Jejeloye, M.B.B.S., Adunola A. Pedro, M.B.B.S., Olufemi Oyekunle, SUMMARY: Ayodeji A. Bioku, M.B.B.S. INTRODUCTION People with mental illness face societal stigma, institutional stigma, and even self SUMMARY: stigma. These attitudes are influenced by media BACKGROUND: In recent times, research has focused representations, including the portrayal of TV on the extent of patients' satisfaction and quality of characters with mental health challenges. Because services rendered in healthcare facilities as one common perception of people with mental indicators of effective healthcare systems. These are illness is that they are generally violent, we set out useful information necessary for the development of to study the use of words that reference a mental programs targeted at improving the overall services illness on top-rated crime shows to see if they rendered within the healthcare settings. There is perpetuated that belief. METHODS This study is an however limited research work on this subject in observational, retrospective, mixed quantitative and Sub-Saharan African setting. OBJECTIVE: This study qualitative study evaluating portrayals of mental assessed the quality of care received and the level of illness on top ranked criminal primetime television satisfaction of patients attending the outpatient shows. Words representing major mental illness department of a public mental health institution in diagnoses, symptomatology, mental health Nigeria. METHODOLOGY: Using a non-probability, facility/provider keywords, slang/derogatory terms convenience sampling method, the level of and general terminology were identified from the satisfaction and the perceived quality of care transcripts of nine dramatic crime series from the received by one hundred patients that assessed the 2014 television season. Our team of authors out-patient clinic of Federal Neuropsychiatric reviewed and categorized each in context as to hospital Yaba were determined. The data were whether it was used accurately and when inaccurate collected with the use of socio-demographic whether it was a positive or negative usage. When questionnaire as well as a modified survey the transcript identified a character who appeared questionnaire. The data were analyzed using IBM- to have a mental illness, the transcript was reviewed SPSS version 20. RESULTS: The mean age of in more detail to determine the role the character respondents was 40.02 ± S.D 10.93 years. The played in the episode. RESULTS After examining the highest mean score for satisfaction was on the transcripts of 210 episodes from nine highly rated drama series, 54% of the words that were examined endured by refugees, contribute to the mental were used inappropriately or in an unprofessional health burden on refugees. The current literature on manner, and of those inappropriate usages, 49% educating refugee caseworkers about available were used in a negative manner and directed toward mental health resources is limited, as are studies a person. Eight words were determined to be used in involving collaboration with mental health providers a negative manner greater than 90% of the time and other health care professionals. This project (nut/nutjob, asylum, lunatic, crazy, deranged, describes a collaborative 3-hour training session insane/insanity, whacko, shrink). Based on the which involved resettlement agency case workers, transcript review, when a character was identified as case managers, psychiatrists, and psychologists who having a mental illness, the character was portrayed work with refugees in Houston, TX. Goals of this as a perpetrator or suspect almost twice as often as training session included facilitating discussion and a victim or witness. DISCUSSION We found that the collaborative problem solving to address common language with mental health implications in popular challenges, to maximize awareness and utilization of crime shows were commonly inappropriate and available services provided to refugees by inaccurate. Additionally, a significantly participants of the training, and to strengthen disproportionate number of characters with a partnerships between providers of services for mental health issue were portrayed as potential refugees. The training format began with a group violent criminals. More study on the use of language icebreaker, followed by small group case-based regarding mental illness and the portrayal of people discussions and process groups, an experiential with mental illness in the media is needed to further mindfulness exercise, a large group discussion on explore the effect of this medium on societal views burnout in the context of working with refugees and towards mental illness. concluded with a discussion of self-care and stress management skills. Outcomes included No. 18 strengthening of the partnership between local Building Partnerships: Using a Collaborative resettlement agency case workers and mental health Training Module With Psychiatrists and Refugee providers, clarification of roles of case workers, case Case Workers to Better Serve Houston Refugee managers, and mental health providers, increased Families knowledge of available community resources for Poster Presenter: Kristen Guilford refugees as well as case workers, improved ability to Co-Authors: Kelly Aylsworth, M.D., Ye B. Du, M.D., screen for mental health issues and effectively refer M.P.H., Sophia Banu, M.D., Diana Prieto refugees to appropriate mental health services when needed. Future directions of study include SUMMARY: conducting a needs assessment of resettlement Since 1975, the US has welcomed nearly 3.4 million agency staff to refine focus of training objectives in refugees from various regions, with nearly 85,000 future modules, as well as expanding this training accepted in 2015 alone. In this same year, 15,866 of modality to include health care provider in these refugees from 43 countries resettled in Texas, specialties outside mental health. including 6834 who resettled in Harris County, which includes the city of Houston. The Houston No. 19 metropolitan area is home to multiple resettlement Mental Health Among Coptic Christians: Barriers agencies staffed with caseworkers who assist and Novel Approaches refugee families in navigating the transition to Poster Presenter: Mena Mirhom, M.D. American culture, the health care system, employment, and integration into society. There are SUMMARY: numerous factors which create challenges and limit Although Coptic Christians, who are the largest available support for refugees, both in the Christian population of the middle east, constitute a community and in health care systems throughout significant presence in North America, their the process of resettlement. These factors, utilization of mental health services remains fairly compounded with traumatic experiences often low. There are cultural and perceived religious prohibitions that hinder access to mental health Poster Presenter: Catalina Trevino Saenz, M.D. services. The shame and stigma in the community is, Co-Authors: Sina Shah-Hosseini, M.D., M.S.E., Raj at times, overwhelming. Lack of insight, language Addepalli barriers, and financial hardship also prove to be significant barriers. In this poster, we discuss a novel SUMMARY: approach of a free mental health clinic where a This is the case of a 53-year-old African American Coptic priest, who is also a licensed psychiatrist, is woman, homeless, with a psychiatric history of the primary mental health provider. We will discuss stimulant use disorder (cocaine), prescription opiate demographic data of the clinic, treatment use disorder, self-reported depressed mood, Medical approaches and outcome measurements of the past history of AIDS, Hepatitis C, Herpes Zoster, Anorectal 5 years. cancer s/p radiation, Laryngeal cancer s/p laryngeal surgery and partial tongue graft, who presented to No. 20 the Psychiatric Emergency Services complaining of Triple Diagnosis: HIV Infection, Substance Abuse, suicidal ideation. Patient reported history of daily and Psychiatric Disorders cocaine use, non-adherence to HAART and home Poster Presenter: Rahn Kennedy Bailey, M.D. psychiatric medications which included Mirtazapine Co-Author: Afrayem Morgan 30 mg by mouth. Upon admission to the inpatient unit the patient was restarted on Remeron 30 mg at SUMMARY: night time and presenting symptoms began to Patients with serious mental illness (SMI) have resolve on second inpatient hospital day. Patient had higher rates of HIV infection than do individuals in history of similar initial presentation requesting the general population, most likely because of their referral to detox/rehabilitations services followed by higher levels of sexual risk behavior and injection a refusal to follow through on referral to an inpatient drug use. Substance use is associated with increased drug rehab program. She also did not follow up sexual risk behavior, poorer health outcomes in repeatedly with HAART treatment and had a CD4 individuals with HIV, poorer HAART adherence, count of 1 and a exponentially high viral load and decreased health care utilization, and poorer was also diverting HAART medications to support her immunologic and virologic outcomes. Management drug use. Patient had history of repeatedly of triple diagnosis is in need of concensus clinical presenting to the hospital in an emaciated, frail, guidelines, including a preventive perspective and a apathetic state reporting chronic pain and reporting model of integrated HIV treatment. The primary suicidal ideation after cocaine use. Extensive modalities of substance abuse treatment models in psychoeducation and motivational interviewing persons living with HIV include cognitive behavioral failed to convince the patient in following through therapy, social support/support group models, with substance abuse treatment, housing referral motivational enhancement/motivational and referral to a specialized residential treatment interviewing, transtheoretical frameworks, and facility for patients with AIDS and comorbid directly observed therapy. It is recommended that substance abuse. Pt constantly rejected referral integrated care systems must also serve as a portal indicating that she was not ready to stop using illicit to address issues such as sexual risk, self-care, and substances and she would consider it in the future. adherence. HIV testing and prevention messages Repeated pleas to at least consider harm reduction should be standard of care in substance abuse strategies failed to enthuse the patient to commit to treatment programs. Existing models of any referrals in the community. This case highlights psychotherapy and substance abuse treatment the difficulty of treating comorbid substance use require contextualizing. Research agendas should along with AIDS when coexisting homelessness and focus on the use of technology. absence of a supportive network hampers attempts to recovery and sustaining wellness in the No. 21 community. Effective treatment may require “I Wanted Help Then… Not Anymore”: Treatment engagement of the patient with outreach teams who Issues in a Patient With AIDS and Cocaine Use will target the patient with multiple encounters in the community with modest goals of using assessment form to be completed at the time of treatment as at least a period of abstinence when a intake, Psychiatric Services and Clinical Knowledge wellness checkup can be performed and medical Enhancement System (PSYCKES) access for clinicians, issues can be uses as a starting point to reengage the warm handoffs prior to discharge, bedside patient in treatment. Respect for patient autonomy prescription delivery, a single organized folder in making decisions and absence of a legal mandate provided to patients at the time of discharge to force patients with comorbid substance use and containing discharge and aftercare instructions, an AIDS unlike assisted outpatient psychiatric treatment outlined readmission reduction plan as part of can frustrate providers who are concerned about the discharge documentation, post discharge follow-up progressive decline in physical health of these calls to patients and outreach calls to aftercare patients. providers, and introduction of a social worker/care manager in the psychiatric emergency department No. 22 setting to facilitate short-term alternatives to Readmission Reduction Strategies at a Regional psychiatric hospitalization. These strategies are Academic Medical Center presented and evaluated with regards to their Poster Presenter: Seema Sannesy, M.D. effects on quarterly data analysis of readmission Co-Authors: Stephen Ferrando, M.D., Eva Carmona, rates, along with specific barriers noted. M.H.A., Hal Smith, M.P.S., Rachel Zinns, M.D. No. 23 SUMMARY: The Alzheimer's Prevention Initiative Generation Repeated psychiatric hospitalization, primarily for Study: A Preclinical Trial in APOE4 Homozygotes those with serious mental illness, continues to be a Poster Presenter: Pierre N. Tariot, M.D. problem nationally. While much focus has been Co-Authors: Jessica Langbaum, Ph.D., Fonda Liu, given to finding the balance between length of stay Pharm.D., Marie-Emmanuelle Riviere, Ph.D., Ronald (LOS) and 30-day readmission rate, the factors that G. Thomas, Ph.D., Robert Lenz, M.D., Gabriel Vargas, influence readmission rates appear to be multiple. M.D., Ph.D., Angelika Caputo, Ph.D., Ana Graf, M.D., Identifiable reasons for psychiatric readmission Cristina Lopez-Lopez, Eric Reiman, M.D. include, but are not limited to, history of previous admission, premature discharge, inadequate SUMMARY: transition support services after discharge, Background: The Alzheimer's Prevention Initiative nonadherence with aftercare and/or medications, or (API) was established to evaluate preclinical simply discharge plan failure. In efforts to reduce 30- Alzheimer's disease (AD) treatments in cognitively day inpatient psychiatric readmissions a regional unimpaired people who, based on age and genetic academic medical center in New York State's Hudson background, are at imminent risk for developing Valley has employed a number of strategies. Integral symptoms of AD. The API APOE4 Trial, also known as to this initiative has been joining the Readmissions the Generation Study, is evaluating the effects of Quality Collaborative (RQC) sponsored by the NYS two amyloid targeted therapies (CAD106 and Office of Mental Health, the Healthcare Association CNP520) in cognitively normal people who, on the of NYS, and the Greater NY Hospital Association, basis of age and being apolipoprotein (APOE) E4 along with formation of a multidisciplinary allele homozygotes, are at particularly elevated risk Behavioral Health Readmissions Reduction of developing symptoms of AD. CAD106 is an active Committee within the medical center. Baseline data immunotherapy against Aß; CNP520 is a Beta-site- analysis of readmissions included the examined APP cleaving enzyme-1 inhibitor. We hypothesize variables of LOS, reason for readmission, discharge that Aß-lowering therapies might be most effective referral, and whether initial aftercare appointment in the preclinical stages of AD, prior to development was kept. Quarterly analyses have been completed of extensive pathology. Identification of APOE4 as various readmission reduction strategies were homozygotes is employed as a prognostic employed over time. These strategies thus far have enrichment strategy to select individuals likely to included introduction of a readmission risk show cognitive decline in the near future. APOE4 homozygotes are at elevated risk of developing paroxetine carry a risk for teratogenicity when symptoms of late-onset AD: by age 85, the risk of prescribed to pregnant women. It is thus essential symptomatic AD reaches 51% for male homozygotes that women of reproductive age receive proper and 60-68% for female homozygotes (Genin et al., psychoeducation and be on multiple methods of 2011). About 70-80% of APOE4 homozygotes age 60- contraception and when prescribed these 75 will have extensive fibrillar Aß deposition (Jansen medications along with the clinician documenting et al., 2015). Methods: Under the auspices of the this discussion. We wanted to evaluate the current Alzheimer's Prevention Registry, we developed a trends and attitudes of clinicians prescribing novel, trial-independent APOE recruitment registry potentially teratogenic medications in our outpatient known as GeneMatch to support enrollment into clinic. Methods: We designed a survey and sent it this and other studies. The Generation Study out to our outpatient prescribers with questions on employs two primary outcomes: time to diagnosis of how often they prescribe medications with MCI due to AD and decline on the API preclinical teratogenic potential to females of reproductive age, composite cognitive (APCC) test. The APCC was how often they educate them about the potential developed as a sensitive tool to detect and track risks to the fetus, about the protective role of folate cognitive decline in individuals at risk for progression (for valproate and carbamazepine), how often they to the clinical stages of AD. The effects of therapy on inquire about pregnancy status and birth control various biomarkers will be assessed as will the methods and finally we included a few questions to extent to which treatment biomarker effects could evaluate their knowledge about the medications' predict clinical benefit. Importantly, the impact of reproductive side effects. We also conducted a chart disclosing APOE4 genotype and associated risk review and identified 79 charts of women of information to older adults will be assessed. Results: reproductive age who have been prescribed at least The global trial, funded by NIH, philanthropy and one of the these medications in the past year (Dec Novartis/Amgen, has just launched. GeneMatch 2015-2016) and collected data regarding how often serves as the primary recruitment mechanism in the prescribers documented that they educated their US; over 40,000 volunteers have been genotyped patients about the reproductive risks, inquired about thus far, of whom nearly 5% are APOE4 birth control method or possible pregnancy or tested homozygotes. APOE4 homozygotes and a random for pregnancy. Results: 9 providers participated in sample of non-homozygotes who consent and our survey. All of them were treating females of appear to meet basic trial eligibility criteria for the reproductive age and 7 of them (77.8%) indicated Generation study are invited to trial sites for that they prescribe to them FDA pregnancy category additional screening and disclosure of APOE D or X medications. The vast majority of providers genotype and associated risk of developing (88.8%) indicated that they have educated their symptoms due to AD. Conclusions: Trial progress to patients about the risks at least once (and 44.4% of date will be summarized. We anticipate that the them indicate that they document this at least every GeneMatch program, which will also be summarized, 3 months) and they have inquired about birth will identify a large pool of prospective participants control methods at least once. 50% of the providers for the Generation Study and future trials. ask about possible pregnancy only the first time they prescribe or do not ask at all, while 77.8% do not No. 24 check HCG. More than half (55.6%) discuss the Assessing the Knowledge and Practice of Clinicians protective role of folate. Regarding providers' Prescribing Potentially Teratogenic Medications in knowledge about medication side effects, all of them an Outpatient Clinic were aware of lithium, but things are not as clear Poster Presenter: Sahil Munjal, M.D. when it comes to benzodiazepines or topiramate. Co-Authors: Anna Karagkouni, Beth Zell, Ifeoluwa Chart review results: In 9/79 charts (11%) it was Osewa, Julia Nahmias, Gohar Khosravi documented that patients were educated regarding reproductive risks, in 9/79 charts (11%) it was SUMMARY: documented that providers inquired about birth Background: Mood stabilizers, benzodiazepines and control method, in 3/79 charts (4%) HCG testing was documented and in 10/79 charts (13%) it was determining and assigning a risk rating for the documented that providers inquired about possible population, care manager qualification, medical pregnancy. Conclusion: The clinicians' knowledge record keeping, obtaining patient consent, financial regarding the reproductive risks of certain reimbursement models as well as provision for psychiatric medications appears to be fair, however, addressing crises situations. CMS billing codes as monitoring for possible pregnancy is not as good. All well as the 2018 replacement AMA CPT Codes (if documentation regarding the aforementioned issues available) are reviewed. Established collaborative has been poor. Our next step is to educate the care programs such as the Mental Health Integration clinicians regarding our current practice, monitor Program in Washington State and the DIAMOND and track the charts for these discussions. program in the State of Minnesota are reviewed as well. No. 25 A Framework to Survive and Prosper in a No. 26 Psychiatric Collaborative Care Setting Disruptive Mood Dysregulation Disorder: A Unique Poster Presenter: Vikram N. Shah, M.D., M.B.A. Pediatric Neuropsychopharmacological Approach Co-Author: William Lopez, M.D. Poster Presenter: Daniel T. Matthews, M.D. Co-Author: Glenda W. Matthews, M.D. SUMMARY: The psychiatric collaborative care model (CoCM) was SUMMARY: developed by the late Wayne Keaton, M.D. and Background: The DSM-5 (296.99)(ICD-10 F34.81) Jürgen Unützer, M.D., M.P.H., M. A. at the diagnosis of Disruptive Mood Dysregulation Disorder Advancing Integrated Mental Health Solutions (DMDD) has minimal research available exploring (AIMS) center at the University of Washington. It is psychopharmacological approaches addressing the an evidenced based model and has proved effective hallmark symptoms of severe, recurrent temper in numerous randomized controlled trials. In the outbursts and persistent irritability that occur, on psychiatric collaborative care model, the primary average, three or more times per week, over a care physician employs a behavioral care manager to period of one year. Recently published studies, provide care management for a caseload of patients resultant from applying the official DSM 5 criteria to with diagnosed mental health or substance abuse large community based mental health populations; disorders. The psychiatrist provides expert advice to indicate three month prevalence rates of 3.3% to the primary care physician. The psychiatrist provides 8.2%. When treated with the currently applied recommendation for the treatment plan and has medication protocols, these studies indicate a poor weekly consultation rounds with the behavioral care long term functional prognosis. Objective: Our manager. If necessary, the psychiatrist assumes current study explores the feasibility of more treatment for difficult cases. Starting January 1, effectively managing DMDD symptomatology with a 2017, Centers for Medicare and Medicaid Services unique medication protocol. The primary (CMS) began reimbursement for psychiatric components include the combination of an collaborative care services. CMS has established anticonvulsant to target mood lability and anger three new billing codes (G0502, G0503 and G0504) outbursts and a dopamine agonist to target to reimburse care provided under the psychiatric impulsivity, irritability, and concentration. Method: Collaborative Care Model (CoCM). In this poster, we Subjects were 91 persistently irritable and explosive focus on how a psychiatrist in private practice can be children and adolescents (52 male, 39 female, ages involved in a collaborative care model. Opportunities 6-17) with previous inpatient treatment for primary for allied disciplines (social work, psychology, nursing diagnoses of bipolar disorder, other unspecified etc.) are discussed as well. We review the evidenced mood disorder, and oppositional defiant disorder. based model that has proved effective in numerous Upon retrospective chart review, all subjects met the randomized controlled trials. The nitty-gritty details diagnostic criteria for DMDD. All subjects were of participation in such a model by a psychiatrist in discharged on a pharmacological combination of an private practice are discussed. This includes anticonvulsant (oxcarbazepine, target dose range 35- 50 mg/kg/day) and amantadine HCl (target dose psychiatric inpatient population. Most research range of 10-15 mg/kg/day). Utilization of currently discusses the harmful effects of S&R use antipsychotic medications was minimal to none. and alternative strategies for reducing its need. This Outpatient providers were supplied with a study aims to find a correlation between certain risk compendium of research articles and information factors and S&R use in the child and adolescent regarding the unique pharmacological approach, and psychiatric inpatient unit. The main aim is to try and requested to comply with the approach, based on look at predictors of those who might be at higher their assessment of the patients' ongoing outpatient risk for S & R events and early identification of these clinical presentation. As a result of parent/caregiver patients and working on an effective treatment plan surveys one year post discharge, providers were to prevent S&R events. A retrospective analysis of grouped into compliant (maintained the protocol children and adolescents admitted to Missouri with minimal to no adjustment), or non-compliant Psychiatric Center at University of Missouri from July (discontinued the protocol, often substituting 2009 to December 2012 was conducted to examine antipsychotic medications). Results: The percent of predictors of S&R use. After IRB approval was re-hospitalization for uncontrolled aggression at one obtained, patients (N = 120) with at least one year post discharge was calculated separately for seclusion or restraint event (N = 159) were those subjects whose aftercare providers were, or identified. An extensive chart review through were not, compliant with the protocol. For the fully electronic medical records was conducted and the compliant, 8% (5 of 64) required re-hospitalization. specific data needed for this study was gathered and For the non-compliant providers, 26% (7 of 27), included in a database. The Chronic Behavioral and required re-hospitalization. Using Chi-square Affective Dysregulation Syndrome (CBADS) analysis, there was a significant relationship questionnaire was created to assess risk factors in between re-hospitalization rates and compliance to the subset of patients who had an S & R event. With the pharmacological protocol (Chi-square, two tailed the help of this instrument several demographic and with Yates = 3.975; P<.05; Phi = .24. Conclusion: The historical clinical variables were collected including results indicate that, for children and adolescents reason for admission, treatment history, placement one year post inpatient discharge for diagnosis of history, self-harm history, suicide attempts, DMDD (retrospective), continuation of the descried aggression history, substance use history, abuse unique medication protocol provides significantly history, in addition to other psycho social variables. lower rates of re-hospitalization. Further controlled Additionally, every seclusion and restraint incident studies are needed. was documented with cause, type of restrictive measure(s), length of time, and any medication(s) No. 27 that were administered. Data will be analyzed for Predictors of Seclusion and Restraints in an descriptive statistics and to look at any correlation of Inpatient Pediatric Psychiatric Hospital: A risk factors on CBADS to S & R events. Since there is Retrospective Chart Review limited research and data available regarding Poster Presenter: Marwa Badawy, M.D. restrictive interventions, more research is necessary to determine whether findings observed are SUMMARY: universally applicable. Understanding risk factors for Seclusion and restraints (S&R) in child and S&R use in the pediatric population will diminish its adolescent psychiatric hospitals are often used to need and ameliorate safety. maintain the safety of the patient and others on the unit. The prolonged use of S&R has been found to No. 28 have negative consequences, both physical and Official Translation of CRAFFT in Korean and Small- psychological, and has not been shown to be Scale Accuracy Assessment effective. S&R use is highly regulated and is only Poster Presenter: Ah Lahm Shin, M.D. used in extreme circumstances when there is an Co-Authors: Jung W. Kim, M.D., John Rogers Knight, imminent risk of harm to patient or others. There is M.D., Patricia Schram, M.D. a paucity of research on S&R use in the pediatric SUMMARY: Background: Since its first introduction in 1999, SUMMARY: CRAFFT has become a standard of care screening Culture, “the integrated pattern of human tool for substance use among adolescent and young knowledge, belief, and behavior that depends upon adults. CRAFFT has been translated into more than the capacity for learning and transmitting knowledge 20 different languages, but there has not been an to succeeding generation is a dynamic, ever official translation version in Korean. Boston changing, evolving, and elusive concept, that is Children's Hospital sets quality standards for the dependent on time, space and subjective accuracy of language translations and cultural experience.” Both health care staff and students adaptations. Our goal in this project is to provide the have greatly benefited from the curriculum of first official Korean translation version and attempt cultural competency, and curiosity about individual to assess its usability in a small-scale study. cultural experiences. Through their clinical Methods: Two bilingual medical doctors, who are experience with the culturally diverse population of fluent in both Korean and English, translated the the Bronx and through their teaching of medical CRAFFT English version into Korean. One of the students and psychiatry residents at Albert Einstein translators was in his final year of child and College of Medicine, the authors propose a well- adolescent psychiatry training and had more than documented individual and family centered four years of practice in psychiatry. The other approach for formulating culture via use of cultural translator did not have any official training in genograms. The genogram is the story of a family psychiatry but had knowledge of CRAFFT through over many generations. In constructing the cultural medical school education. Three non-medical genogram, the therapist and patient/family can bilingual Koreans, whose primary language was explore together the richness of the family and the Korean, then back-translated the Korean translation individual’s history including migration and into English. The project investigators then immigration, race, ethnicity, religion, gender identity compared the original English and back-translation values and expectations, socioeconomic class, and versions to assess the accuracy of the translation experiences of power and oppression. The process is and the understanding of linguistic and cultural humanizing, enriching, and a way of opening nuances by non-medical persons. Results: dialogues about central themes which might not be Preliminary cross-comparison shows that our Korean discovered if discussion were limited to the translation version was accurate, well understood by individual’s focus. In the poster presentation, non-medical bilinguals and adequately theoretical ground work to support this approach accommodated the linguistic and cultural nuances. will be provided, as well as clinical vignettes and Conclusion: In our paper, we first present an official genograms to demonstrate its utility. Further Korean version of CRAFFT that is linguistically discussions will emphasize the benefits of utilizing accurate, understandable to non-medical Korean “the patient as an educator” approach. Clinical bilinguals, and culturally appropriate. This Korean examples utilizing this conceptual framework and version is to be publically available through the methods will demonstrate impact on access and Boston Children's Hospital website. effectiveness of care in a diverse population, as well as on training clinicians in teaching institutions. We No. 29 will consider ethical implications as well as the value WITHDRAWN of these techniques in medical education, in the context of a growing content rather than process No. 30 oriented care. The Cultural Genogram Revisited: Finding a Path to Ensure Patient-Centered Cultural Formulation and Poster Session 3 Promote Effective Mental Health Education and Care No. 1 Poster Presenter: Uri Meller, M.D. Delusional Parasitosis: A Literature Review and Co-Author: Madeleine S. Abrams, L.C.S.W. Case Report Poster Presenter: Allen Dsouza, M.D. Literature recommends ruling out true organic skin Co-Authors: Ghulam Khan, M.D., M.B.B.S., disorder, empathic listening ,asking the patient how Veeraraghavan J. Iyer the condition affects the patient's life, referring the patient to a psychiatrist and starting antipsychotics SUMMARY: as ways to approach the case. Pimozide was the drug Delusional parasitosis is a false, firm belief that some of choice for treatment however because of its side parasite has infested their body. It is a rare disease effect profile it has made way for second generation and is seen in 2.37-17/million/ year. The antipsychotics as drug of choice. Risperdone and approximate male to female ratio is 1:3. It can be Olanzapine have shown good efficacy in treatment seen after adolescence in young adults or elderly of Delusional Parasitosis. Conclusion: Patients with people. The peak age being 40-60 years. We present Delusional Parasitosis might come across as rigid and a Case report of a Patient who presented with difficult. Team work, building trust and rapport with Delusional parasitosis and was treated with the patient, use of antipsychotics can be helpful. Risperidone. Case Report: Patient is 56 year old Psychotherapy can benefit with reducing anxiety and female with a history of Anxiety Disorder who self mutilating behaviors. presented with complaints "parasites are running around my head" and constant itching over her scalp No. 2 and other exposed parts of her body. She reported Treatment Strategies for Negative Symptoms in that she noticed "a white looking translucent Schizophrenia parasite running around her scalp." She also Poster Presenter: Ganesh Kudva Kundadak, M.D. reported calling exterminators into her house multiple times with no success. She reported feeling SUMMARY: significant distress because multiple dermatologists Negative symptoms represent some of the most and ER visits. She underwent skin biopsies , used skin treatment-resistant and debilitating symptoms of lotions, topical creams and antihistaminics with no schizophrenia, and contribute substantially to the relief. Physical examination showed bald patches on social and economic burden of the illness. Mental the scalp, multiple lesions over her arms, legs, neck Health Services often struggle to help patients and back which resemble two point scabs. afflicted with negative symptoms, which persist long Dermatology team evaluation had no significant after positive symptoms have been remedied. In this findings and referred the patient to the Psychiatry poster, we shall critically review the existing team for Diagnosis of Delusional Parasitosis. Medical literature to appraise the available pharmacological work up showed no significant findings. She was and non-pharmacological treatments for negative started on Risperidone 0.5 mg twice a day and dose symptoms. In so doing, we hope to formulate a was uptitrated to 2 mg twice a day. Patient gained potential treatment plan for such patients. In our some insight into her illness and was followed up out review, we found that pharamcological agents like patient. Follow up evaluation over months showed memantine and oxytocin may significantly improve significant improvement in her condition. Discussion: social functioning, antipsychotics like amisulpride are Patients with Delusional Parasitosis are often useful in addressing negative symptoms, and evaluated by a number of physicians in the past. cognitive therapy has a role in alleviating avolition Patients describe a crawling sensation or pruritis as and apathy. Our conclusion is that, whilst more the first evidence of infestation. A pathognomonic research is required on the subject, an ideal course sign is the "matchbox sign" wherein patients usually of action would involve a combination of bring bottles, bits of skin, lint or tissue as antipsychotics such as amisulpiride or olanzapine, "specimens' to prove the existence of the parasite. with a promptly instituted and comprehensive They may present with skin lesions often caused by occupational therapy programme. self inflicted injuries with a probable effort to remove the parasite by scratching, skin picking, use No. 3 of needles, knives or finger nails. These patients are The Clinical (Mis)Diagnosis of Schizophrenia in usually reluctant to seek Psychiatric care or referral. African Americans Poster Presenter: Robert Daniel La Bril, M.D., M.Div. conclusion. The extent to which patient characteristics (i.e. differences in symptom SUMMARY: presentation, co-morbid mental illnesses, help Background: It has been acknowledged for at least seeking behavior, cultural mistrust, genetic 50 years that African American (AA) patients are predispositions, epigenetic influences) and factors significantly more likely than non-Latino/a White influencing the clinical diagnostic process (i.e. (nLW) patients to be clinically diagnosed with ethnocentrism, explicit and implicit bias, clinical schizophrenia (SCZ). Search Methods: The following uncertainty, rating of patient symptoms, cultural data bases from 1960 to November 29, 2016: differences, DSM criteria, hospital type, protocols, PubMed MEDLINE, PsycINFO, and Web of Science and location) remain unclear. More research is using multiple combinations of the following MeSH needed to more clearly document the reasons for terms; African American (AA), African Continental higher rates of diagnosed SCZ for AAs compared to Ancestry Group, Diagnosis, SCZ. To capture nLWs. additional articles, the Journal of the National Medical Association was hand-searched from 1960- No. 4 2016 in addition to scanning reference lists of eight Motivational Interviewing for Chronic Psychiatric articles. Finally, consultation with an expert in the Patients Who Experienced Weight Gain and field was made to identify additional articles. Metabolic Syndrome Selection Criteria: Articles were selected if they were Poster Presenter: Lidia Klepacz, M.D. published in English between1960-2016; peer Co-Authors: Elizabeth Leung, Annie Xu, M.D. reviewed, included AA patients having a diagnosis of SCZ or described AA symptoms of SCZ . Data SUMMARY: Collection and Analysis: Two review authors Non-adherence to antipsychotic medication is highly screened abstracts to determine relevance, those prevalent in patients with chronic schizophrenia and deemed relevant received full paper reviews. Any other psychotic spectrum disorders. Non-adherence disagreements were resolved by discussion. If no in this population has been a major obstacle to long- agreement was reached, then a third author made term maintenance treatment and contributing to the final decision. Provisional Results: After high relapse rates. Studies have shown that patients reviewing 856 articles and approximately 124 full- are not adhering to medications for various reasons; text papers, 100 articles were included. Inter-rater one of the major reasons is due to the significant agreement was .864, indicating a strong level of adverse effect on weight gain and metabolic agreement . The next steps of the scoping review are dysfunction. Atypical antipsychotic medications are to: (1) describe publication frequency from 1960- first line treatment for schizophrenia, 2016; (2)record publication type, hospital settings, schizoaffective, bipolar and other psychotic study designs, age groups studied, presence of spectrum disorders. However, they are notably comparison groups, studies showing (or not) a associated with obesity, other components of higher proportion of AAs, compared to nLW metabolic syndrome, diabetes, and cardiovascular Americans, diagnosed with SCZ, where appropriate, disease. Metabolic syndromes are seen in 42.6% of level of agreement between a clinical and research men and 48.5% of women in patients chronically diagnosis; and (3) list hypotheses employed to treated with antipsychotic medications according to explain why AA patients receive a diagnosis of SCZ at some studies. Motivational interviewing is a style of higher frequencies than nLW. Provisional patient-centered counselling developed to facilitate Conclusions: The number of articles produced per change in health-related behaviors. The core year steadily increased from the 1960s to the 1980s. principle of the approach is negotiation rather than Articles steeply increased from the 1990s to the conflict. Evidence has shown that motivational early 2000s and have decreased since then. Most interviewing is effective in assisting people with studies argue that AA with mood disorders are substance use to achieve positive result through misdiagnosed as having SCZ but the absence of an behavioral changes. In the past decade, motivation accepted "gold standard" further complicates this interviewing has been applied to focus on patients on long-term antipsychotic medication who underwent routine screening mammography as per experienced weight gain as a major side effect United States Preventive Task Force guidelines, through adherence therapy focused motivational which revealed incidental finding of left invasive interviewing, with or without other interventions ductal adenocarcinoma. The patient underwent that facilitates lifestyle changes. However, the surgical removal of the tumor and total mastectomy nature of the symptoms secondary to the illness has and was started on chemotherapy with agents posted a lot of challenges in treatment course. The Cyclophosphamide and Doxorubicin. This case aims limited ability to engage comfortably in to illustrate the challenges faced in managing a relationships, coupled with positive symptoms of patient on Clozapine while receiving chemotherapy. paranoia, represents a major barrier to treatment Treatment strategies, medication side effects adherence and sustained behavior change. On the monitoring, and recommendations will also be other hand, negative symptoms cause problems with discussed. self-expression, naming and recognizing emotions, and verbalizing thoughts, as well as many other No. 6 elements of forming and sustaining relationships; “She’s Not My Sister!”: A Case Report of Capgras and these may hinder the expression of change talk. Syndrome in a Patient With Schizophrenia and In this poster, we will review literatures and Vascular Dementia available studies on the utility and challenges of Poster Presenter: Lauren Pengrin, D.O. applying motivational interviewing with or without specific modifications to focus on medication SUMMARY: adherence in patients who experience weight gain, • The clinical description of the Capgras Syndrome obesity, and metabolic syndrome secondary to appeared in the literature as early as 1893. In this chronic use of antipsychotic medication. syndrome, the patient believes that a person, usually a family member, has been replaced by an exact No. 5 duplicate or imposter and maintains this false belief Managing a Patient on Clozapine Who Is Receiving despite evidence to the contrary. Capgras' syndrome Chemotherapy During Inpatient Psychiatric has been reported with various organic disorders, Admission including subarachnoid hemorrhage, and head Poster Presenter: Pankaj Manocha, M.D. injury. A patient was admitted to the general Lead Author: Luisa Gonzalez medical floor for poorly controlled diabetes. She has Co-Author: Nikhil Anbarasan a history significant for hypertension, diabetes mellitus and schizophrenia. Psychiatry was consulted SUMMARY: to evaluate the patient's psychiatric medications and Breast cancer is the most common cancer in women, make recommendations/changes as necessary with a lifetime risk of 1 in 8 in the general during her hospitalization. The patient said that she population1. Literature review indicates that the noticed her sister had been replaced by a "double" incidence of cancer in patients with psychiatric many months ago and she avoided spending time illness is equivalent to the general population, but with her. She denied believing that any other friends there is a 30% higher case fatality rate from cancer or family members were also imposters. The patient in psychiatric patients2. Several factors including late has a past psychiatric history of schizophrenia, which presentation and poor access to health care are developed in her early 20s. She had multiple cited as contributing factors. We present one such hospitalizations and has been on many psychotropic case of a 50-year- old homeless, unemployed medications throughout her life with inconsistent woman, with no family support that was brought to compliance. She was taking haloperidol 10mg PO at our hospital by police, psychotic and disorganized. bedtime and had been taking this for the past five The patient was started on Clozapine after failed years. She reports a history of hypertension and response to different psychotropic medications for diabetes mellitus, though she admits that she does persistent treatment-refractory psychosis with not take her medications as prescribed. She denied depressed mood. While on the unit patient also substance use now or ever in the past. The patient denied seizures or traumatic brain injury in the past. psychiatry service. The skin was severely damaged, On mental status exam, pertinent findings included so the assistants determined psychiatry paranoid delusions regarding her sister and hospitalization. The pacient also associated the delusions of her sister being replaced with an eruption of worms with a supposed "enchanted "imposter look alike." The patient also had some plate of food" given from a neighbor whom she difficulties with memory and attention, and an already had negative thoughts. Besides that, she MMSE score suggested a comorbid diagnosis of performed from a long time daily rituals wich dementia. Upon discovering that the patient was envolves cleaning, organization and religious suffering from Capgras syndrome, the question was activities. In this episode, she was treated by a raised if she was also suffering from any organic multidisciplinary team, received antipsychotic, brain disorders. After discussion with the medical antidepressive and antihystaminic medication, team, brain imaging was ordered, which revealed improving psychotic and obsessive symptoms and multiple old cerebral infarcts and severe sclerosis of yet achieving great cicatrization from skin lesion. We the vessels. This prompted the medical team to report a pacient with delusional infestation (Ekbom's make significant changes to her medications for Syndrome), condition that the sufferer assumes a management of hypertension. The diagnosis of self-mutilation behaviour (scratching, harming, Capgras syndrome also changed the psychiatric cutting) in order to eliminate parasites. This treatment plan. The patient was started on syndrome is associated with several psychiatric clozapine, and the haloperidol was discontinued. The comorbidities, in this reportes case, previous history patient's symptoms of psychosis remained very well of obsessive symptoms that turned into a delusional controlled, and she slowly began to engage with her disorder, somatic type, was identified. Conclusion: sister as her treatment continued. The link between observing the complexity of psychopatology and yet Capgras Syndrome and organic brain dysfunction is the low prevalence of this condition, the study aim is well established in the literature and when Capgras to review literature of this disorder and analyse the syndrome is associated with neurodegeneration, psychopatology envolved. there is likely an older age at onset than if it were associated with a non-neurodegenerative disease. No. 8 This presentation aims to educate the audience Metformin Use for Metabolic Abnormalities and about Capgras Syndrome and the link between Weight Gain in Adult Patients With Schizophrenia: organic and psychiatric etiologies for psychiatric A Systematic Review symptoms. Poster Presenter: Tatiana Brancalião Silveira Co-Authors: Priscila Zempulski, Maira Aguiar No. 7 Werneck, Natalia M. H. O. Santos Delusional Infestation in a Patient With Poor Insight Obsession Symptoms SUMMARY: Poster Presenter: Natalia M. H. O. Santos Objective: Metabolic syndrome (MS) and weight gain Co-Authors: Victor Capelo, Leonardo Jesus, Maira has been recognized as a risk factor for Aguiar Werneck, Tatiana Brancalião Silveira, Priscila cardiovascular morbidity and mortality in general Zempulski population and in patients with severe mental illnesses, like schizophrenia. Using concomitant SUMMARY: medications to counteract these adversities may be S.R, female, 49 years old, reached dermatology a rational option. This systematic review examined ambulatorial service complaining of "worm the effectiveness of metformin (MT) to prevent or eruption" on her skin, six months from current date. treat weight gain and metabolic abnormalities in Epidermal excoriation was associated to the emerge patients with schizophrenia. Method: Searches in of this worms. She storage in a box a huge amount english, spanish and portuguese language in the of supposed worms, asking for a professional electronic database PubMed with the keywords: examination of debris. Dermatologist realized that "Schizophrenia OR Psychotic Disorder " AND the escoriation was self perpetrated and sent her to "Metformin OR Glucophage " AND "Weight Gain OR Weight Loss OR Body Mass Index OR Metabolic serotonin reuptake inhibitor (Fluoxetine) after 7 days Syndrome OR Metabolic Disease OR Blood Glucose of use. The patient showed full remission of the OR Blood Pressure OR Cholesterol OR Tryglicerides" maniac episode after 2 weeks of the onset of AND "Antipsychotic" were performed. Four symptoms, after starting treatment in a psychiatric metformin randomized controlled clinical trials ward. This material provides a reflection on the (RCTs) using placebo in schizophrenic patients using importance of a continued and assisted antipsychotics were included in this systematic pharmacological intervention, including biological, review. These RCTS were published in english and psychological and social aspects of the patient, as involved 324 subjects. Results: Metformin was well as the risks associated to avoid morbidities. significantly superior to placebo in the primary Keywords: Mood Disorder; Bipolar Disorder; outcomes measures (body weight, body mass index, Psychotic Mania; Induced Mania; Fluoxetine. fasting glucose) and in the secondary outcomes (fasting insulin, HOMA, waist circumference, waist- No. 10 hip ratio). Conclusion: This systematic review Suicidal Behavior in Schizophrenia Inpatients in the suggests that adjunctive metformin is an effective, United States, 2002–2012 safe, and reasonable choice for antipsychotic- Poster Presenter: Mehran Taherian induced weight gain and metabolic abnormalities. Co-Authors: Rhaisa Dumenigo, Juan D. Oms For this reason, choosing this particular drug should be considered after a psychosocial intervention it SUMMARY: has proven ineffective. Keywords: Schizophrenia; BACKGROUND Compared to the general population, Metformin; Metabolic Syndrome; Weight Gain; people with schizophrenia have a more than eight- Antipsychotic drugs. fold increased risk of suicide. Among people diagnosed with schizophrenia, an estimated 20% to No. 9 40% attempt suicide. Identification of risk factors for Fluoxetine-Induced Psychotic Mania: A Case Report suicide is a major tactic for predicting and preventing Poster Presenter: Tatiana Brancalião Silveira suicide. The aim of the present study was to study Co-Authors: Maira Aguiar Werneck, Priscila the prevalence of, and factors associated with Zempulski, Natalia M. H. O. Santos suicidal ideation and suicide attempts among schizophrenia inpatients in the United States SUMMARY: between 2002 and 2012. METHODS Data from the The Major Depressive Disorder (MDD) is considered Nationwide Inpatient Sample (NIS) hospital one of the medical illnesses of most prevalence and discharge database (Healthcare Cost and Utilization severity in our society, with high psychosocial and Project, Agency for Healthcare Research and Quality) functional damage. Different pharmacological for the period 2002-2012 was retrospectively classes of antidepressants, as selective serotonin reviewed. All hospitalizations with a primary reuptake inhibitor (SSRIs), may increase the risk of diagnosis of schizophrenia from the International hypomanic and manic episodes, although its Classification of Diseases, 9th revision, Clinical mechanism is not fully elucidated. Such episodes Modification (ICD-9-CM) were selected for analysis. usually happen in patients with bipolar depression, Suicidal behavior (including suicidal ideation and even though, it may occur in patients with unipolar suicide and self-inflicted injury) was identified using depression. I hereby report a case of a manic standard ICD-9-CM codes. The Student's t-test was episode with psychotic symptoms in a 38-year-old used to compare the mean in continuous variables. man, with MDD diagnosis made by a non-specialist Multivariate logistic regression (IBM SPSS 22.0 doctor (general practitioner) characterized by software) was performed on the schizophrenia expansive mood, inflated self-esteem, decreased cohort with or without suicide. A p-value <0.05 was need for sleep, anxiety, hyperactivity, psychomotor considered to indicate statistical significance. agitation, distractibility, racing thoughts, mistic- RESULTS An estimated total of 3,254,554 religious hallucinations, auditory hallucinations and hospitalizations were identified between 2002 and heteroaggressiveness induced by a selective 2012 (mean± SD age 43.0±13.7, 57.7% male) with a primary diagnosis of schizophrenia. 49.0% were sign interpreters to identify whether a deaf patient is white followed by 34.3% black. Of all schizophrenia experiencing psychosis as opposed to limitations hospitalizations, 323,713 (9.9%) had suicidal with communication (5). Very few studies of the behavior (mean± SD age 41.2± 12.2, 61.1% male, deaf psychiatric population exist, and most are 51.2% white). The rate of suicidal ideation was 9.9%, descriptive and anecdotal (6). No well-controlled and suicide attempts 0.6% The most common outcome studies of deaf people with psychosis have primary payer in schizophrenics with suicidal been conducted (6). There is controversy about the behavior was Medicare (42.1%) followed by exact nature of auditory-hallucinations reported by Medicaid (40.7%). Suicidal behavior in schizophrenia prelingually deaf people with psychosis (3,6). When patients was associated with a higher comorbidity profoundly prelingually deaf people with psychosis rate of drug abuse (adjusted odds ratio [OR], 1.36, report hearing voices, it is unlikely that they are p<0.001), alcohol abuse (OR, 1.14), tobacco smoking referring to the same experience that hearing people (OR, 1.85), medication nonadherence (OR, 1.29), with psychosis have, simply because they do not depression (OR, 2.74), other neurological disorders have the same framework for "hearing" (1). People (OR, 1.27), AIDS (OR, 1.34), obesity (OR, 1.37), with schizophrenia who are profoundly deaf from hypertension (OR, 1.11), and hypothyroidism (OR, birth do not describe experiences of sound-based 1.17). CONCLUSION Suicidal behavior was more "voices" and cannot describe pitch, loudness, or common among white male schizophrenics with volume characteristics of the "voices". The subvocal medication nonadherence, and was significantly articulation hypothesis suggests that auditory- associated with comorbidities of substance abuse hallucinations result from the misattribution of inner and depression. Thus, identification and active speech to an external locus of control (7). The treatment of depression, improving adherence to subvocal hypothesis posits that the form of the treatment, and maintaining special attention to hallucination mirrors subvocal thought processes, patients with comorbid substance use disorders are which in hearing individuals are predominantly essential and are likely to reduce the risk of suicidal speech-based (7). Further research is needed to behavior in schizophrenia. evaluate deaf people who show greater heterogeneity in how they experience auditory- No. 11 hallucinations due to individual differences in A Literature Review of Deaf Patients With Psychotic experience with language and residual hearing (3). Disorders Who Report Auditory Hallucinations Furthermore, there is a lack of brain imaging or Poster Presenter: Amilcar A. Tirado, M.D., M.B.A. experimental studies, and no research has been Co-Author: Marieliz Alonso, M.D. conducted to compare how "voices" are perceived by those who were born deaf and those who lost SUMMARY: their hearing after acquiring speech (7). At the Deafness is not a uniform phenomenon but exists to present time, research on deaf psychiatric patients varying degrees, ranging from profound prelingual with psychotic disorders is scarce in the scientific deafness, in which the person has had no experience literature (6). When deaf psychotic patients report of hearing sound at all (acquired prior to 3 years of "hearing voices," they undoubtedly are experiencing age), to restricted hearing only in those frequencies something. Just what that is however, is not known. required for verbal communication, to central Moreover, hearing mental health professionals may auditory processing deficits in which a person has have to come to terms with the fact that they most the full frequency range of hearing but cannot likely will never be able to know that this experience meaningfully process these sounds (1,2,3). A deaf is unknowable, because they do not share deaf patient's ability to communicate may be hampered phenomenological frames of reference (1). by language dysfluency. The most common cause of language dysfluency in deaf patients is language No. 12 deprivation due to late and inadequate exposure to Ketamine Infusion Protocol for Determining Long- American Sign Language (4). Language dysfluency Term Effectiveness in the Treatment of Refractory can make it also challenging for health providers and Depression Poster Presenter: Mah-Rukh W. Anjum in patients and their healthy attendants at medical Lead Author: Ranjith D. Chandrasena, M.D. OPD of Civil Hospital Karachi. Patients &Methods: Co-Authors: Julie D. Handsor, R.P.N., Terri Lariviere, Patients attending medical OPD were administered R.P.N., Alex Leonard, B.M.Sc. DSM-IV questionnaire comparative observational. An equal number of healthy attendants with the SUMMARY: patients were selected as control. Diagnosis of Ketamine infusion for treatment refractory depression was made if DSM-IV score of = 5 was depression is now considered an innovative present. Frequencies of depression were compared treatment & not an experimental approach. The with control. Two groups were analyzed on the basis literature however is not clear about the duration & of gender, marital status, education, and occupation. frequency of treatments for improvement and Results: During the study, 236 patients and an equal sustaining improvement. Some studies have number of controls were included. The mean DSM- recommended daily treatments or twice weekly IV score was significantly higher in the patient group treatments for 3 weeks. Serial ketamine infusion (3.8/Standard Deviation?) as compared with control treatments of 0.5 mg/kg twice weekly have been group (1.6/ Standard Deviation?). The number of found to be beneficial but literature does not depressed subjects in control group was 19 (8.1%) indicate which patients will sustain improvement and that in the patient group was 99 (41.9%), the over a period of time as well as there is no clarity on difference was statistically significant (x2 test; p- treatment regimen. Our program uses an innovate value <0.001). No difference in frequency of approach using serial MADRS scores to determine depression was found on basis of marital status but which patients remain under a score of 16, for 4 significant differences were found on the basis of weeks or longer for the maintenance phase , after 1- gender, education, and occupation. Conclusion: 3 initial weekly treatments . Patients diagnosed as Significant numbers of patients attending the treatment refractory are offered infusions based on medical OPD were depressed. MADRS score of >16. About a third of patients continue to sustain improvement over 4 weeks with No. 14 MADRS < 16 .Their GAF scores show significant Suicidality in Depressed Patients With ADHD: A improvement over the period of intermittent Nationwide Longitudinal Study treatments compared to baseline. So far 79 infusions Poster Presenter: Saad Salman, Pharm.D. have been administered to 28 and 9 patients Co-Authors: Sajid Asghar, Fahad Hassan Shah, continue to be on the Ketamine maintenance Jawaria Idrees, Zunaira Nauman, Ayesha Dar, program. Three quarters of all the patients require a Muhammad Usman, Turfa Nadeem, Hafsa Bibi treatment interval of 4 weeks and more going up to 35 weeks. There is a bimodal distribution of 4 and 7 SUMMARY: weeks between infusion intervals, with a median of Background Suicide in depressed patients' is one of 5.5 weeks. Our innovative approach provides a the major health concern and gained substantial solution determining which patients are best suited attention in public health fields. However, the role of for maintenance on Ketamine infusions to improve attention-deficit/hyperactivity disorder (ADHD) in their level of functioning & quality of life. suicide attempts among patients with co-morbid different types of depressions remain unknown. No. 13 Methods We identified 1397 depressed adolescents Comparison of Depression Frequency Among and adults: post-partum depression (n=145), pre- Outpatients and Their Healthy Attendants at Civil menstrual dysphoric-disorder (n=196), bipolar Hospital Karachi, Pakistan disorder (n=535) and major depression (n=521) with Poster Presenter: Faisal Kagadkar, M.B.B.S. co-morbid ADHD from 2001 to 2010 in Pakistan and Lead Author: Hudaisa Hafeez, M.D. Afghanistan from 116 major hospital's record and matched according to gender (587 males, 810 SUMMARY: females) and age (11-17) with 6335 (control) Objective: To determine the frequency of depression patients with types of depression alone; a longitudinal cohort observed until the end of 2015. reviews of pharmacological interventions will be Patients with other psychiatric comorbidities were summarized with focus on varenicline in excluded from the study. Findings Patients with combination with nicotine replacement therapies. major depression and ADHD had a greater incidence Second, unmotivated individuals not yet of completed suicide than those with any depression contemplating quitting often do not receive a key type alone (2.9% vs. 0.9%, p = 0.006). After brief psychotherapy that can elicit a change in their adjustment for psychiatric comorbidities, a cox- motivation. There is a myth that patients with regression analysis demonstrated that the mental illness and substance use disorders do not independent risk-factor for attempted suicide, later want to quit or that cannot be motivated to quit. in life was ADHD, among depressed patients (HR: The audience will understand the most recent 3.12, 95% CI: 1.44-4.27). Interpretation Adolescents evidence-based psychosocial interventions for with comorbid major depression and ADHD had an smoking cessation with focus on motivational elevated risk of attempted suicide as compared to interviewing techniques. patients with any other type of depression alone. This is the first study, of its kind, to demonstrate an No. 18 independent influence of ADHD on attempted Addressing Implementation Challenges in Assessing suicide among different types of depressed young Mental Health Disorders in Primary Care adults and adolescents. We have not assessed risk of Poster Presenter: William Emmet suicide due to other psychiatric co-morbidities. Co-Authors: Carol Alter, Karen Sanders, Angela Kimball No. 15 WITHDRAWN SUMMARY: The integration of behavioral health with primary No. 16 care starts with the primary care clinician's WITHDRAWN willingness to assess and treat their patients' mental health disorder, yet primary care practitioners are No. 17 overworked and underpaid, and asking them to add Smoking and Mental Illness: Stop Hitting the an additional assessment is often a non-starter. Snooze Button Issues around clinician mindset, workflow, patient Poster Presenter: Edwin Kim, M.D. engagement and clinical decision-making need to be Co-Authors: Anil A. Thomas, M.D., Jose Vito, M.D. overcome to address mental health needs of primary care patients that exacerbate medical comorbidities SUMMARY: and their accompanying costs. Use of electronic If the first step in enhancing access to effective care based multicondition assessments that deliver is eliminating barriers to treatment, then results directly to the electronic medical record can psychiatrists can no longer subscribe to outdated streamline workflow and facilitate clinical decision beliefs. This presentation will identify obstacles, making. It improves access to care, enables which limit potential success of smoking cessation in measurement of results, and encourages patient mental health, and outline scientific evidence and engagement. This poster will demonstrate ways to effective psychotherapy skills that can be applied address the barriers in primary care that limit uptake while treating individuals motivated to quit and of screening for behavioral health disorders and those not yet ready to quit. First, motivated show how they can be overcome through electronic individuals, despite their desire to quit smoking, data collection, measurement, and effective often do not receive interventions shown to reduce utilization. nicotine cravings. There is a myth that pharmacological options don't work or make mental No. 19 illness worse. The audience will understand the most “Hey, Doc! I Need Double Portions”: The Planning recent evidence-based pharmacological and Implementation of a Nutrition Program in a interventions for smoking cessation. Cochrane Community Crisis Residential Unit Poster Presenter: Chanda Mayers-Elder Co-Authors: Nathalie Butler, Jenna Lin No. 20 Withdrawal of Stimulant Medication in an Adult SUMMARY: With Intellectual Disability, Autism, Childhood Supporting healthy lifestyle changes is one of the ADHD, and Challenging Behavior more challenging tasks in treating persons with Poster Presenter: Richard Hillier serious mental illnesses. Doing this in a community Co-Author: Rupal Patel, M.B.B.S. mental health setting with limited funding is even more challenging. Research shows that persons with SUMMARY: serious mental illness tend to have a decreased Ms. H.F., a 22 year old woman of mixed ethnicity lifespan on average of 25 years earlier the general with a moderate intellectual disability, autism, population due to treatable medical conditions such challenging behaviour and a childhood diagnosis of as cardiovascular, pulmonary and infectious ADHD. The patient was living in a purpose built one diseases. While mental health professionals bedroom flat and supported by one carer at all oftentimes encourage healthy lifestyles, considering times. She presented to psychiatry due to the metabolic effects of certain psychotropic longstanding issues around challenging behaviour, medications, a significant number of persons served repetitive behaviours and poor sleep. Challenging may not fully understand this concept. Furthermore, behaviour was in the form of physical aggression those who are indigent, under-/uninsured or towards carers and property destruction, often seemingly marginalized often cannot fathom how occurring when demands were placed on H.F. From this can be attainable especially when food sources functional behaviour analysis, it was shown that may be limited to shelter, soup kitchen or food bank there were several serious episodes of challenging provisions. Crisis residential units (CRUs) were behaviour with no apparent trigger. The patient was established as an alternative to hospitalization for taking Concerta 36mg am and 18mg pm which had voluntary admissions. They are also utilized as a been initiated in childhood for the treatment of "step-down" option for those who no longer meet ADHD symptoms. Following discussion with the criteria for inpatient hospitalization and are in need family and carers, we agreed to gradually reduce and for further stabilizing on medications in a structured stop Concerta. Follow up at 6 weeks was positive and therapeutic environment. CRUs aim to support with reported improvements in levels of agitation recovery through various group programming, case and anxiety. Incidents of challenging behaviour had management, individual therapy and medication reduced and the patient was engaging in more management in an attempt to help persons served activities both inside and outside of the home. In develop better coping mechanisms in preventing or addition, carers reported improvements in sleep alleviating symptoms that may lead to further from 4-5 hours to 7-8 hours post cessation of decompensation in functioning. CRUs in community Concerta. In this poster, we discuss the increasing mental health networks tend to have limited trend to use stimulant medication in adults with budgets and have similar challenges with supporting ADHD. In this case example, we report an healthy food options as shelters, soup kitchens, and improvement in presentation and behaviour in a food banks falling short on reinforcing that patient with intellectual disability and autism component of overall wellness. This workshop will following withdrawal of Concerta XL, possibly due to address the challenges in planning and executing a a reduction in anxiety levels. nutritionally-balanced menu in a community CRU. Through audience participation, participants will No. 21 learn creative ways to educate patients on how to Switching Our Pitch and Drumming to a Different incorporate healthier food options into their diets Beat: Strengths-Based Interventions for Exceptional and empower them to adopt other positive lifestyle Minds changes despite severe budgetary and housing Poster Presenter: Lamis Jabri, M.D. limitations. SUMMARY: When learning about Autism Spectrum Disorder important suggestions for clinical/educational (ASD) and other neurodevelopmental disorders, we strategies. Second, we describe existing innovative are trained to identify deficits, provide timely strengths-based interventions for speech/language referral for multidisciplinary assessment, and development, self-help and social skills, and proactively seek evidence-based interventions. emotional regulation. These are drawn from the Despite the irrefutable helpfulness of the literature as well as the named experts' clinical therapeutic strategies designed to address specific experience through the programs they have deficits in speech/communication, designed. Finally, we describe specific success stories behavioral/emotional regulation, self-help and social illustrating how to expose, foster and promote skills, we argue that there remains a problem with talents and strengths to help individuals with our "deficit-based" approach. Indeed, during and neurodevelopmental concerns attain higher beyond the school years, there remains a great need education and gainful employment. for strengths-based educational and employment opportunities for individuals with No. 22 neurodevelopmental disorders. Despite the Current State of Training in Autism Spectrum significant challenges they face, many children and Disorder and Developmental Disabilities Across young adults who exhibit symptoms of ASD (or other New York State Psychiatry Training Programs neurodevelopmental disorders) also exhibit Poster Presenter: Lan Chi Krysti L. Vo, M.D. exceptional skills and talents: reading/writing early, visual and auditory memory, musical and other SUMMARY: artistic talent, mathematical abilities etc. These Background: Psychiatric management of children range from remarkable to prodigious. Often, care- with autism spectrum disorder and intellectual takers and professionals alike are unsure how to disability (ASD/DD) can be complex. A recent study conceptualize these abilities. At worst, these are found that almost half of directors of child and considered "splinter skills", and are discouraged, for adolescent psychiatry (CAP) fellowships endorsed fear of hindering the progress of development. At the need for additional resources for training on best, amazement is expressed, but the potential is ASD/DD (Marrus et al 2014). The goal of this system left unexplored. As a mother and a clinician, I felt of care project is to evaluate the current status of disheartened when faced with these specific training in ASD/DD and to identify the specific types concerns with my own son, then diagnosed with ASD of resources that may helpful to psychiatry training at age two. A frantic online search led me to the directors in the state of New York. Methods: General work of Dr. Darold Treffert on Savant syndrome, psychiatry and CAP training directors from Hyperlexia and giftedness. I reached out to him, as Accreditation Council for Graduate Medical hundreds of families had over the years. Upon his Education (ACGME) institutions in New York State recommendation, I consulted and met with were surveyed. This included 31 general psychiatry respected professionals who designed innovative program directors and 16 CAP program directors. strengths-based interventions in their respective Directors were emailed a link to the survey in Sept- disciplines to address the needs of individuals with Oct 2016. The initial email was followed by two neurodevelopmental disorders: Susan Rancer (Music reminders email, allowing a total of 3 weeks to therapist), Jim and Julia Billington (Hidden Wings respond. Respondents were not anonymous as they school), Phyllis Kupperman (Speech and Language were instructed to write the name of their program therapist). Hoping this information would be useful as question #1 of the survey. Participation was to all of us at the front lines, these renowned voluntary and there was no reimbursement. The professionals all graciously agreed to allow me to survey consisted of 7 multiple-choice, 2 multi-select describe their ongoing work herein. First, we present and 2 free response questions for a total of 11 new insights into diagnostic and prognostic questions. The survey was programmed using differences between ASD, Savant Syndrome and SurveyMonkey. Questions focused on the following: Hyperlexia through careful analysis of over 200 (1) educational exposure to ASD/DD through clinical cases from Dr. Treffert's database, leading to didactics and clinical cases; (2) available clinical settings for clinical exposure; (3) interest in administration, and student clinic leaders identified additional resources and (4) preference for type of a need for health education and support for healthy additional resources.Data were analyzed in relationships, body, and mind. A discussion series, Microsoft Excel (2016). Graphs were created using "Girl Talk", was implemented during August 2016 to Microsoft Excel. Results: The response rate was July 2017. Format of these monthly 2-hour sessions 63.8%. Fifty percents of programs have residents included open discussion, didactic time, reflective with 7 or more clinical cases with ASD/DD in a year activities, and workshops. The topics focused on and 83.3% of programs gives six or less didactic personal challenges faced by the women in their lectures regarding management of ASD/DD. Most daily lives such as violence and past trauma, barriers programs (86.7%) would like more resources to and potential solutions to healthier eating on a strengthen training in ASD/DD. When asked which budget, incorporating exercise for mental health, top three resources would be most useful to birth control, and parent-child relationships. Verbal trainees, the choice with the most preferences was feedback was solicited from participants. Depression online videos available anytime with 56.7% of screening at the SFHCC: During August 2016 to May preferences, follow by live in person lectures and 2017, the SFHCC directors were trained and patients reading package, both at 50% of the preferences. (>=18 years) were screened using the Patient Health Conclusion: Our results suggest that many training Questionnaire (PHQ-2). PHQ-9 was provided if PHQ- program directors would like more resources to train 2 score was >3. Quality assurance chart reviews residents and fellows about ASD/DD. Training were performed to assess depression screening program directors' top preference for training rates. Results: Seven sessions of "Girl Talk" were curricula was online video lectures. They are also conducted with 46 Apostle's House women and 36 interested in a wide variety of other resources. student facilitators. Over the course of the year, 48 These findings will be discussed with the American out of 71 patients that visited SHFCC received PHQ-2 Academy of Child and Adolescent Psychiatry Autism (68%) and 13 out of 14 patients who screened and Intellectual Disabilities Committee and the positive on PHQ-2 received PHQ-9 (92.8%). With the American Association of Directors of Psychiatric reinstitution of the depression screening training, Residency Training. It would be critical to develop a the screening rate of PHQ-2 increased from 49% to curriculum on ASD/DD that contains a wide variety 68% during this period. Results indicated that 47% of resources for training programs. had moderate to severe depressive symptoms. Conclusion: (1) The "Girl Talk" program was very well No. 23 received and is continuing for a second iteration as Promoting Mental Health at a Student-Run Free well as being incorporated into regular clinic Clinic With Community Outreach and Quality activities. The women were more aware of the Assurance resources available to them. Students fostered Poster Presenter: Manjiri Nadkarni, M.S. greater trust and relationships with the participants. Co-Author: Shivani Patel We also collaborated with another student organization to provide voluntary childcare services SUMMARY: during these sessions so more women could Background: Medically underserved and vulnerable participate. A hybrid support and didactic group run patient populations face challenges that can impact by medical students can be a fruitful expansion of mental health. We provided two interventions to student-run free clinics to address mental health and improve mental health in the Newark community wellness concerns identified through community through the Student Family Health Care Center needs assessment, benefiting both community and (SFHCC). (1) We provided a patient education medical student members. (2) Continued training program at a homeless shelter outreach site: and reminders for students are important to Apostle's House. (2) We worked on improving maintain improvement in depression screening depression screening at SFHCC through a quality rates. Quality assurance for depression screening assurance project. Methods: Apostle's House programs should be conducted by student-run free Education Program: Apostle's House women, clinics and can inform future screening programs. knowledge; post-curriculum competence increased No. 24 to 7.41 from 4.28 pre-curriculum. Pre-curriculum, Improving Psychiatry Resident Knowledge in Eating 27.6% of residents noted they would refer ED Disorders Using Live and Simulated Patients: Early patients elsewhere due to their perceived lack of Experience With Curriculum Development knowledge on ED. As a stark difference, 0% of Poster Presenter: Ashley G. Ellison, M.D. residents post-curriculum would refer patients elsewhere. Conclusion: Preliminary results of this SUMMARY: study demonstrate that residents have a lack of Background: Since the 1950s, the incidence of eating evidence-based knowledge, low self-perceived disorders (ED) has been steadily increasing. Anorexia confidence, and low self-perceived competence in nervosa continues to have the highest mortality rate ED. The initial 26 participants demonstrate that after of any mental illness. Despite this, psychiatry a curriculum is taught, residents greatly improve residents receive on average less than five hours their fund of knowledge, confidence, and total of ED lectures during their four-year residency. competence in addition to having a greater Twenty-four percent view their ED instruction as willingness to accept patients with ED. More inadequate. Additionally, no formalized curriculum curriculum series are being taught to additional exists to teach residents about ED. As a result, residents to allow sufficient power for statistical psychiatrists post-residency often decline to care for analysis. patients with ED due to their lack of knowledge. Herein we present the initial evaluation data from an No. 25 ongoing ED curriculum being recently instituted at My Brain Won’t Let Me Sleep: TBI and Insomnia Tulane University psychiatry residency program and Poster Presenter: Adekola Alao, M.D. its impact on resident knowledge. Methods: Literature review was performed to evaluate the SUMMARY: components needed for a curriculum on ED. A 5.5 Traumatic brain injury (TBI) affects nearly 1.5 million hour curriculum was created which included a 2- individuals in the United States each year. During hour evidence-based lecture on anorexia, bulimia, peacetime, over 7,000 Americans with a diagnosis of binge eating disorder, and other ED. The curriculum TBI are admitted to military and veterans hospitals involved a presentation and question/answer every year; this number increases significantly during session with a live patient in recovery from an eating combat, during which TBI may comprise up to 20% disorder. There was a simulated patient session in of survivor casualties. Pain and discomfort relating to which residents interviewed and managed a injuries are frequent causes of insomnia or sleep simulated patient with an ED. Pre-curriculum, disturbance in TBI patients. Sleep disturbance can residents completed a 20-item assessment test manifest as difficulty falling or staying asleep, early measuring their fund of knowledge in ED; they also morning wakening and non-restorative sleep, and rated their confidence (defined as their self- affects up to 30% of individuals with TBI. Because perceived comfort in managing ED) and competence there are few studies on pharmacotherapy for sleep (defined as their self-perceived evidence-based disturbances in TBI, many physicians base their clinical knowledge) on a 1 to 10 scale. Post- intervention on experience with the general curriculum, residents completed repeated the 20- population. A literature review was performed and item assessment and rated their confidence and recommendations for treatment of sleep competence. Results: 26 psychiatry residents have disturbances in patients with TBI are summarized completed the curriculum thus far. Average post- here based on published findings. Conclusion Non- curriculum assessment score was 72% compared to pharmacological means should be the first-line pre-curriculum score of 52%. Residents felt more treatment for sleep disturbances in patients with comfort in treating ED post-curriculum with post- TBI. These include sleep hygiene and cognitive curriculum confidence increasing to 7.41 (on a scale behavioural therapy. Physicians and other clinicians of 1 to 10) compared to 4.41 pre-curriculum. should lend careful attention to the specific sleep Residents also had improved self-perceived clinical complaint, adverse effect profile of the medication, as well as the anticipated duration of treatment TMS. PHQ-9 decreased by 91.3%, GAD-7 decreased before deciding upon a sleep agent for patients with by 95% and BDI-II decreased by 81.1%. In regards to TBI. References 1. [CDC] Centers for Disease Control hypersomnia, PHQ-9 Q3 & Q4 decreased from a 6 to and Prevention. 2008 Jan 22. Traumatic Brain Injury. a 1. This was consistent with his reported resolution http://www.cdc.gov/ncipc/tbi/TBI.htm Accessed 3 of his excessive daytime sleepiness, lack of energy April 2008. 2. Ouellet MC, Beaulieu-Bonneau S, and overwhelming exhaustion. Conclusion: Left Morin CM. Insomnia in patients with traumatic brain prefrontal cortex high frequency deep repetitive injury: frequency, characteristics, and risk factors. J transcranial magnetic stimulation may be beneficial Head Trauma Rehabil 2006; 21(3):199-212. 3. Wu R, in the treatment of central hypersomnolensce. Bao J, Zhang C, Deng J, Long C. Comparison of sleep Discussion: A confounding factor in this case is the condition and sleep-related psychological activity fact that the patient had a depression, which can after cognitive-behaviour and pharmacological also manifest with sleepiness and fatigue. It is therapy for chronic insomnia. Psychother Psychosom unlikely that all the improvement in sleepiness was 2006; 75(4):220-8. due to remission of the depression. A potential mechanism for improvement after high frequency No. 26 deep TMS, is that long term daily high frequency Left Prefrontal Cortex High-Frequency Deep TMS TMS increases cortical excitability in a long-term- Alleviates Central Hypersomnolence: Case Report potentiation like fashion. This increase in neuronal Poster Presenter: Manish Sheth, M.D., Ph.D. firing in the meso-cortico-limbic projections and other projection may compensate for the SUMMARY: deficiencies caused by the loss of hypocretinergic Title: Left Prefrontal Cortex High Frequency Deep neurons. TMS Alleviates Central Hypersomnolence: Case Report Authors: Manish Sheth, M.D., Ph.D., Shashita No. 27 Inamdar, M.D., Ph.D., Newshaw Karkhanehchin, B.S., Integrating a Nutritional Intervention Education for Katie Nguyen B.S., Brandyn Roach, B.A., Mayra Patients With Serious Mental Illness Into the Ramirez, B.A. Background: Patients with myotonic Psychiatry Clerkship dystrophy frequently exhibit excessive daytime Poster Presenter: Shinnyi Chou sleepiness. Narcoleptic patients, exhibit excessive daytime sleepiness, shortened sleep latency, SUMMARY: shortened REM latency, fragmented sleep and sleep Need: Recent increase in Primary and Behavioral attacks. Central hypersomnia is a significant cause of Health Care Integration Model (PBHCI) utilization to disability in both of these disorders. The circadian combat care disparities in patients with serious rhythm and recovery time necessary after sleep mental illness (SMI) has led to higher accessibility deprivation are unchanged in these patients but and reduced ER visits.1,2 However, PBHCI is not their wake promoting signals are affected. We routinely incorporated into medical education, and treated a 41 year-old-man with treatment resistant there is no consensus as to an effective strategy. major depressive disorder, narcolepsy and myotonic Purpose: Contact-based education may reduce dystrophy type I with deep TMS to the left prefrontal negative physician attitudes toward patients with cortex (L-PFC). Previously failed medications for SMI.3 We present here a clerkship PBHCI experience depression included: Wellbutrin, Lexapro, Cymbalta that aims to reduce stigma, raise awareness of the and Abilify. Previously failed medications for interplay between psychiatric and preventive care, hypersomnia included: Nuvigil Methods: Thirty daily and cultivate the sensibility that optimal outcomes sessions of dTMS were administered over the L-PFC for individuals with SMI require an integrated using the Brainsway H-1 Coil at 18HZ, 120% of approach. Methods: Psychiatry clerkship students resting hand MT, totaling 1980 pulses per day. assigned to Community Alliance Mental Health Progress was assessed with the PHQ-9, BDI-II and Agency were paired with patients for a three-part GAD-7. Results: The patient's depression and nutritional intervention program. Students excessive daytime sleepiness remitted with the deep facilitated discussions regarding biopsychosocial barriers toward a heathy lifestyle and basic nutrition outcomes, 2) decrease stigma of mental illness knowledge. They then led shopping and cooking among medical students through service learning in workshops with patients, teaching strategies for longitudinal outpatient psychiatric care, and 3) build cost-effective, health-conscious purchases and food leadership skills with peer-teaching in the context of preparation methods. Activities were supervised by a multidisciplinary healthcare team. METHODS: the Agency's wellness coordinator and students Carolina Outreach identified patients with comorbid processed the experience with the coordinator post psychiatric and medical conditions who necessitate intervention. Outcomes: Overall students believed additional coordination of their medical care. A team the experience to be worthwhile. Initially, students of 2 medical students (1 first year, 1 third year or were "nervous about working with individuals with above) served as health care liaisons for each serious mental illness." After the intervention, they patient. Through monthly visits with ACT team staff, became "more comfortable… working with student teams worked with each patient to identify patients with a history [of mental illness]" and health goals and facilitate progress toward those "rather than only focusing on their mental health, goals. Senior students taught and led the first year learn to look at the whole individual to promote students in motivational interviewing toward their overall health." Feedbacks were reviewed achieving these health goals. Students also incorporated accordingly, including providing encouraged conversations about medical conditions "education in nutrition" for students and a and medication compliance and facilitated regular "fundamental piece of literature that explains food primary care appointments for each patient. nutrients" for patients. Conclusion and feasibility: Students also attended weekly didactic sessions on Students appreciated the PBHCI experience and the diagnosis, treatment, and medical comorbidities handled the sometimes unpredictable nature of of severe mental illness as well as goal setting, working with patients with SMI well. There is motivational interviewing, and health behaviors improved perception of working with this population coaching. RESULTS: In order to measure the and increased appreciation for psychiatry. Clients effectiveness of our program, we conducted baseline also consistently responded positively to Agency and end-point surveys of both the patients and personnel. We anticipate minor modifications going medical students. We assessed patient attitudes forward, as the program becomes an established about behavior change through the Patient component of clerkship experience at this Activation Measure and used the Short-Form 12 community site. Health Survey to assess if these motivations actually led to changes in patients' quality of life. We tracked No. 28 medication adherence, appointment attendance, A Program Partnering Medical Students With ACT and progress towards their self-identified health Teams to Improve Chronic Medical Conditions in goal. We assessed medical student attitudes towards Patients With Severe Persistent Mental Illness patients with mental illness and toward the field of Poster Presenter: Heather Burrell Ward, M.D. psychiatry through the Belief Towards Mental Illness Scale and the Balon Attitudes Towards Psychiatry SUMMARY: Scale, respectively. CONCLUSION: Medical students INTRODUCTION: There is great need for better may be able to improve chronic medical conditions primary care follow up in the mentally ill population. in patients with severe mental illness by Their chronic mental illness, coupled with lack of coordinating care between ACT teams and primary health literacy, marginalized socioeconomic status, care providers and by facilitating discussion about and comorbid medical conditions, prove to be patients' health and behaviors. Service learning is an prohibitive barriers to care. To address this need, we effective way to decrease the stigma associated with created a novel program that partnered medical mental illness. students with Carolina Outreach's Assertive Community Treatment (ACT) team. Our purpose was No. 29 threefold: 1) empower patients to affect change in FIT Clinic Peer Support Group: Easing the Mental their health behaviors and improve their health Burden of Re-Entry in the Incarceration Capital of the World intervention surveys every six months over the next Poster Presenter: Zachary Lenane year.

SUMMARY: No. 30 The U. S. imprisons more people than any other Empowering Underserved Youth: An Adolescent country in the world. Within the U.S., Louisiana has Mental Health Initiative Serving Urban Middle the highest incarceration rate, with twice the Schoolers average state per capita rate. Formerly incarcerated Poster Presenter: Nancy Shenoi, B.S. persons are sicker and have significantly higher rates Co-Author: Juliann Tea, B.S. of mental illness than the general population. They are more likely to have experienced trauma as SUMMARY: children and adults, and incarceration itself is a Mental health disorders account for a considerable traumatic stress capable of causing post-traumatic disease burden in Houston, Texas, where more than stress reactions following release. These individuals 152,000 children are living with a psychiatric also face numerous social barriers to medical and diagnosis in the metropolitan area's largest county, mental health care due to their formerly Harris County. Early interventions can foster incarcerated status. Regular counseling in particular resilience, reinforce healthy behaviors, and has been largely unavailable to this population due introduce coping mechanisms and stress- to a lack of available, affordable services for management techniques. A mental health uninsured and Medicaid patients in the New Orleans curriculum developed by Baylor College of Medicine area. The Formerly Incarcerated Transitions (FIT) medical students, psychiatry and pediatrics Clinic was started in 2015 by Tulane School of residents, child and adolescent psychiatry fellows, Medicine faculty and students to provide free and school faculty, was introduced to students at transitional healthcare and case management Yolanda Black Navarro Middle School, a low-income services for individuals recently released from prison public middle school in Houston, Texas where 97% of in Louisiana. Funding from the 2016-2017 Helping students are economically disadvantaged. Mental Hands Grant has allowed the FIT Clinic to begin health and general health classes were taught by addressing the mental health needs of this medical students biannually with support from population. The sessions focus on the practical Citizen Schools, a national non-profit organization aspects of re-entry and the emotional impact of dedicated to closing the opportunity gap by incarceration. They are led by formerly incarcerated providing various after-school learning options to at- individuals and mental health specialists associated risk students. The two ten-week module courses, with Positive Living Treatment Center (PLTC), a "Me, Myself, and I", which addressed mental health community mental health services organization. awareness, and "Medical Madness, " which focused Participants are recruited through the FIT Clinic, its on the human body, gave students a chance to community partners, and outreach by formerly discuss social stressors and empowered them to incarcerated participants. Those who are interested improve their health and well-being. Medical and have completed the re-entry process are student mentors encouraged students to pursue recruited as discussion leaders. Fourteen sessions careers in the health professions and anonymously have been held since September, 2016 with a surveyed them on the program's impact and median attendance of 15 participants. The program efficacy. At the program's conclusion, middle school is currently being evaluated. Year one (current) scholars recognized the need to address mental participants will complete anonymous, post- health topics including bullying, relationships and intervention surveys assessing satisfaction with the drugs, while learning about emotional regulation program (CSQ-8), perceived social support (SSQ6), and interpersonal communication. PTSD symptoms (PCL-5), and depression symptoms (PHQ-9) in September, at the end of the grant No. 31 period. Year two participants will complete pre- Cognitive Screening for Referral to Cognitive intervention surveys in October and post- Remediation in Outpatient Psychiatric Rehabilitation: Prevalence of Impaired Cognition differences suggest the use of different global Across Diagnoses criteria for cognitive impairment. Poster Presenter: Raymond Kotwicki, M.D., M.P.H. Co-Author: Philip D. Harvey, Ph.D. Saturday, October 21, 2017

SUMMARY: Poster Session 4 Background: Cognitive remediation therapy (CRT) interventions are increasing in their use in No. 1 outpatient settings. These interventions have Stigmatization and Challenges in Diagnosing Adult demonstrated their efficacy for improving functional ADHD outcomes when combined with appropriate Poster Presenter: Lidia Klepacz, M.D. rehabilitation interventions. However, most of these Co-Authors: Elizabeth Leung, Annie Xu, M.D. interventions have been targeted at outpatients with schizophrenia. It is not clear how many cases with SUMMARY: other conditions would manifest cognitive ADHD has long been thought to be a disabling and impairments and whether baseline screening would common disorder that occurs only in childhood, be an effective triage tool. This study addressed this more recent researches suggest that ADHD persists question. Methods: Consecutive admissions (N=337) into adulthood in high proportion of cases. It is to a residential and outpatient young adult estimated that up to 4.5% of adults meet diagnostic rehabilitation program were administered the Brief criteria for ADHD. ADHD is associated with other Assessment of Cognition for Affective Disorders comorbid psychiatric disorders such as substance (BAC-A) at the time of admission. Diagnoses were use, affective disorder, personality disorders, and obtained with the MINI International Psychiatric also remarkable correlation with poor socio- Inventory. A cut-off t-score of 40 (one SD below the economic outcome and functional impairment. normative mean), a MoCA score of ≤ 25, and or ADHD is also associated high work impairment with designation of the Cognition and Frist Episode (CAFÉ) a statistically significant 22.1 annual days of excess Track were the criteria used for selection of cases in lost role performance compared to those without need of CRT. Results: The sample received diagnoses ADHD. Adult services, however, for people with that were bipolar disorder for 23%, major depression ADHD remain relatively scarce despite strong for 48%, and schizophrenia 12%. Other diagnoses evidence for the benefits of diagnosing and treating were less common. The sample was 52% female. ADHD in adults. There are still many professionals Overall 22% of the cases met criteria on the BAC-A that are unsure of the diagnosis and the appropriate for impairment based on a t-score of 40 or less. The use of ADHD medications in adult mental health. proportion of cases who met criteria was quite Some continue to express fears about treating a similar across diagnoses, although the schizophrenia "non-existent disease" or causing drug addiction sample was considerably smaller. Thus, a minority of with stimulant medication. The reasons for this are cases were cognitively impaired. Discussion: In a likely to be based on the historical perception of younger sample of patients seeking psychiatric ADHD as a disorder that is restricted to childhood rehabilitation, the presence of global cognitive and the continued presence of stigma and clinical impairment was lower than reported in previous mythology that surrounds the disorder and its studies of similar diagnostic groups (Reichenberg et treatment; and the traditional separation of adult al., 2009). The sample manifested considerable from child psychiatry. What is clear is that there everyday disability, but this facility does not accept remains a gulf in the perception of the disorder Medicaid/Medicare for payment demographics may between those working in child and adolescent be different than in broader samples. Cognitive mental health services and those working in adult impairment in these patients at this facility has been mental health, that cannot be explained on the basis previously reported to correlate with everyday of validated evidence based information. Stigma disability (Vargas et al., 2014), so the demographic related to the term ADHD is one component of the problem that nearly always arises in the context of lack of awareness or understanding of available However, patient has noticed increased appetite data. Within the mental health professional stigma is since the Aripiprazole was introduced to her regimen further associated with the restricted regulatory despite regular three times weekly exercise not status for most of the medications that treat ADHD changed from baseline. One month since in adults. ADHD in adults remains a disorder which is Aripiprazole started, patient has experienced a ten poorly understood and where an emotional burden pounds weight gain. Aripiprazole was discontinued is attached to the term especially among at patient's request due to intolerable hyperphagia professionals who have not traditionally been and weight gain. Patient's hyperphasia subsided as involved in the diagnosis or treatment of ADHD. Aripiprazole was discontinued and her weight People suffering from ADHD are often stereotyped returned to her baseline in two months. Conclusions: as lazy, bad or aggressive, or considered to have a Hyperphagia and weight gain experienced in this behavioral or special needs problem rather than a patient is a result of a not commonly reported side mental health disorder that requires treatment. The effects of Aripiprazole. In this poster, we will discuss diagnosis may also be overlooked because ADHD is and review literatures on hyperphagia and weight highly symptomatic disorder and those less familiar gain associated with Aripiprazole, and comparison of with the onset, course, psychopathology and metabolic profile with other atypical antipsychotic comorbidities associated with the disorder may agents. mistake ADHD for other common mental health conditions. In this poster, we will discuss and review No. 3 literatures regarding to the stigma and challenges in Economic Utility of Combinatorial diagnosing adult ADHD. Pharmacogenomic Testing in Patients With Bipolar Disorder and Generalized Anxiety Disorder: A No. 2 Prospective Analysis Aripiprazole-Induced Hyperphagia and Weight Poster Presenter: Lisa C. Brown, Ph.D. Gain: A Case Report Co-Authors: Raymond A. Lorenz, Pharm.D., B.C.P.P., Poster Presenter: Annie Xu, M.D. James Li, M.S., Bryan M. Dechairo, Ph.D. Lead Author: Elizabeth Leung Co-Author: Lidia Klepacz, M.D. SUMMARY: Anxiety disorders such as generalized anxiety SUMMARY: disorder (GAD) are the most prevalent psychiatric Context: Atypical antipsychotic medications are disorders in adults and are frequently comorbid with associated with metabolic syndromes, weight gains major depressive disorder (MDD). Treatment costs secondary to hyperphagia, adverse cardiovascular for anxiety disorders exceed $42 billion per year. profile, and diabetes mellitus. Aripiprazole, a newer Anxiety disorders are also associated with many atypical agent, has been noted by several literature, physical comorbidities, adding to the cost of treating clinical trials and studies that has lower incidence of this illness. Bipolar disorder (BD) often goes the above mentioned adverse effects comparing to undiagnosed or may be misdiagnosed as unipolar other atypical antipsychotics. We present a patient depression for years. While BD is not as prevalent as who developed hyperphagia after Aripiprazole was unipolar depression, BD is twice as costly. The cost introduced as an augmentation agent for depression burden of BD lies in this misdiagnosis as well as cost and a subsequent weight gain of 10 pounds in one of treatment, which often involves a high level of month. Case report: A 55 year-old female with polypharmacy. Often, patients suffering from anxiety history of Major Depressive Disorder, mood disorders and BD begin a treatment regimen of trial symptoms had previously been stable on Citalopram and error, leading to low compliance, high for years presented with worsening depression in polypharmacy, adverse events, and lack of response. context of psychosocial stressors. Aripiprazole was In order to minimize trial and error prescribing and started as augmentation agent for her worsen mood. to guide treatment in a more personalized way, Patient's mood symptoms were effectively clinicians utilize combinatorial pharmacogenomic stabilization after such medication adjustment. testing. Combinatorial pharmacogenomic testing incorporates pharmacokinetic (PK) and an alarming problem as the rate of prescriptions pharmacodynamic (PD) genes into a proprietary continues to rise.In light of the scarcity in these algorithm to predict what medications may be more adverse effects evidence-based treatment, we genetically appropriate for a specific patient. present the case of a 49yo Hispanic female with Patients taking psychotropic medications whose history of depression treated with oral steroids for treatment was guided by GeneSight® psychotropic severe asthmatic/COPD exacerbation developed showed a savings of $1036 in medications costs manic and psychotic symptoms.This served as the compared to patients whose treatment was not stimulus for our literature search on steroid induced guided by the test. This current report presents a mania treatment options.Even though, psychiatric subanalysis of that data pertaining to medication disturbances can occur at any point during savings for anxiety disorders and BP compared to treatment, most occur early in the therapeutic MDD. Over the course of 1 year, we prospectively course with mania as the most common.Changes in collected pharmacy claims data of over 13,000 dopamine, cholinergic, serotonin and glutamate patients. We analyzed pharmacy spend for patients system, as well as in alterations in hippocampal with GAD, BD, and MDD whose treatment was neurons plasticity has been found to play a guided by pharmacogenomic testing compared to role.These findings have facilitated the guidance without the testing as well as potential treatment/management of steroid psychosis and cost-savings when medication treatment decisions enabled the implementation of preventive were congruent with the report. Patients with GAD prophylaxis by manipulating monoamine levels. Still, saved $6747 (p<0.004) per member per year (PMPY), the most effective treatment is complete BD patients saved $4952 (p=0.14) PMPY, and MDD discontinuation of the offending agent.For patients patients saved $3738 (p<0.004) PMPY when that cannot tolerate steroid cessation or lower doses medication decisions were congruent with the pharmacotherapy may be required. Depending on pharmacogenomic report compared to incongruent the monoamines levels affected, the psychotropic decisions. Much of the cost savings was directly medication classes effective in idiopathic psychiatric related to CNS medications but included a large syndromes, can be extrapolated in the management percentage of non-CNS medications like of steroid-psychiatric symptoms. Many psychotropic antineoplastic, cardiovascular, gastroenterology, and medications have been explored with some diabetes medication classes. Overall, this study success.For corticosteroid-induced depression and found that medication treatment costs for GAD and mania, case reports have supported use of BD can be significantly reduced when utilizing antipsychotics, lithium, valproic acid, and combinatorial pharmacogenomic testing to guide carbamazepine.In a systematic review, steroid- treatment decisions. induced manic and psychotic symptoms responded to low-dose typical antipsychotics with cessation of No. 4 symptoms in 83% of patients, 60% of whom WITHDRAWN responded in less than 1 week and 80% in less than 2 weeks.Olanzapine has also been reported in an No. 5 open-label trial and case series to be beneficial for Steroid-Induced Mania: Case Report and Literature patients with multiple underlying illnesses and Review steroid-induced mixed and manic Poster Presenter: Sahil Munjal, M.D. episodes.Additionally, a case series showed that Co-Authors: Virginia Ramos, Moeed Ahmad sodium valproate rapidly and safely reversed manic- like symptoms within a few days without needing to SUMMARY: stop corticosteroids, allowing medical treatment to Since their discovery in the 1930s, steroids have continue.Given what we learned from the literature been widely utilized for the treatment of numerous search, we started our patient on risperidone.Due to conditions.In comparison to the other well-known minimal improvement, it was discontinued and physiological side effects, little has been instead given aripiprazole and documented about psychiatric disturbances.This is Depakote.Unfortunately, patient's symptoms persisted and her medication was changed to changes were not clinically significant. Similarly; 80% haloperidol and valproic acid.Within a few days, of patient showed a decrease in hemoglobin patient began to show improvement and after a 33 (0.43±0.38 g/dL), while the rest of 20% showed an day hospitalization, she was discharged.Steroids increase of 0.3 ±0.0 g/dL. The changes in value of have shown to be a powerful tool with significant hemoglobin were not significantly different (P=NS). . adverse effects.Thus, it's essential to educate patient But the number of patients affected by drop in and caregiver on potential warning signs of hemoglobin were greatly higher (P<0.05). This data psychiatric effects for the prevention of unwanted show that clozapine might also affect erythropoiesis. symptoms. Further studies with larger patient population and longer treatment duration are needed to address No. 6 this issue. WITHDRAWN No. 8 No. 7 Use of Fluvoxamine Augmentation for Relief of Effect of Clozapine on Red Blood Cells Clozapine-Induced Constipation Poster Presenter: Chandresh Shah, M.D. Poster Presenter: Sina Shah-Hosseini, M.D., M.S.E. Co-Authors: Pronoy Roy, Raj Addepalli SUMMARY: Clozapine is a highly effective antipsychotic drug and SUMMARY: is the only one which has received FDA-approval for This is a case of a 38 year old Bangladeshi woman treatment of treatment-refractory schizophrenia. with past psychiatric history of schizoaffective Unfortunately, it is associated with rare but fatal disorder on clozapine who presented to our hospital side-effect of agranulocytosis. In view of this many complaining of severe constipation, depression, and health regulatory authorities all over the world have command auditory hallucinations to kill self. The implemented clozapine monitoring systems. In 2015, patient was admitted to the inpatient psychiatric Food and Drug Administration (USA) rolled out unit and continued on clozapine treatment. While Clozapine Risk Evaluation and Mitigation Strategies perceptual symptoms resolved shortly after (REMS). This would help the providers with early administration of clozapine 550 mg/day, symptoms warning signs, would alert pharmacy with missed of depression and constipation persisted. Despite opportunity of intervention and ultimately provide administration of multiple stool softeners and bowel adequate and timely safeguard to patients. The regulating agents, there was little improvement of focus of Clozapine REMS has been ongoing constipation, causing the patient significant distress. monitoring of blood's myeloid lineage, namely of Medical and Gastroenterology consult team White Blood Cell as well as Neutrophil. To study recommendations for relieving constipation included effect of clozapine on erythroid lineage of discontinuation of clozapine due to the hematopoiesis, records of all 10 patients receiving antimuscarinic side effects. The patient was clozapine were reviewed for their laboratory tests reluctant to discontinue clozapine, as trial of other before starting treatment and then at intervals of 3 antipsychotics had failed in the past, and clozapine months, 6 months and 12 months. There were 9 was the only agent that effectively treated her male patients (age=49.11 ±16.18 years) and 1 female psychiatric symptoms. Augmentation of clozapine (age=59.23 years). There were 40% White, 30% with asenapine 10 mg/day helped in resolution of Black, 10% Hispanic and 20% Asian patients. They all psychiatric symptoms. Subsequently the dose of were diagnosed with Schizophrenia. At the end of 12 Clozapine was reduced to 250 mg/day, and months of treatment with clozapine, 60% of patients fluvoxamine 100 mg/day was added to the regimen. showed downward trend in total Red Blood Cell This allowed the substantial reduction of clozapine (RBC) count (0.53 ±0.45M/uL) while the rest of 40% dosage and maintenance of therapeutic clozapine showed an upward trend in total RBC count (0.05 levels and subsequent improvement of debilitating ±0.03M/uL). The decrease in total RBC count was constipation. We discuss our strategy to ameliorate significantly greater (P<0.05), even though these the antimuscarinic effects of clozapine and improving compliance by decreasing dosage of reduction in weight and BMI in these patients clozapine. This was primarily achieved by making use compared to other antipsychotics. Likewise, the of the drug interaction of fluvoxamine with clozapine patient in this study also had a 20-pound weight loss. in a beneficial way. Fluvoxamine inhibits Other data suggests that loxapine may contribute as cytochrome P450(CYP)1A2 for which clozapine is a much to extrapyramidal symptoms as typical agents. substrate, and results in maintenance of therapeutic In this poster, we discuss the possibility of this levels of norclozapine and total clozapine levels at adverse side effect of the rarely utilized loxapine and lower doses of clozapine. The outcome in our case the ambiguous nature of the medication's was relief of severe constipation along with characteristics, some of which appear to be amelioration of psychotic symptoms. comparable to atypical antipsychotics and others of which are more similar to typical agents. At the same No. 9 time, we highlight the potential benefits to be Development of Diabetic Ketoacidosis in a Patient gained from further characterization of the on Loxapine, a Clozapine Analog properties of this low cost agent, which may have Poster Presenter: Kerry A. Sheehan better efficacy on negative symptoms than many Co-Authors: Amanpreet K. Mashiana, Douglas J. other available antipsychotic agents and is also Opler available in a novel formulation as the only inhaled antipsychotic medication. SUMMARY: Ms. M., a 61-year-old woman with a past psychiatric No. 10 history of schizophrenia and cocaine use disorder, Diagnostic Dilemmas: Managing Psychosis, presented to the psychiatric consultation service Delirium, and Catatonia in a Medically Ill Patient with a one-month history of weakness and falls. She Poster Presenter: Elia E. Acevedo-Diaz, M.D. was admitted to the inpatient medicine service for Co-Authors: Rachel Meyen, Sparsha Reddy, M.D. treatment of abscesses, acute kidney injury, and diabetic ketoacidosis (DKA). The patient had been SUMMARY: diagnosed as borderline diabetic six years prior, but Case description: A 71-year-old medically ill African did not have any follow up testing or treatment for American male with schizoaffective disorder, bipolar diabetes in the interim. Around the time that the type, and post-traumatic stress disorder was symptoms that prompted the current admission first admitted to the medical service for management of started, she was switched from haldoperidol to stage IV sacral decubitus ulcer and acute kidney loxapine in order to minimize adverse effects. injury secondary to recurrent urinary tract infection. Loxapine is considered a typical antipsychotic, but His prolonged hospital course was complicated by has a structure similar to clozapine. Although ongoing delirium and psychosis, punctuated by generally considered one of the most effective episodes of catatonia. Discussion: When catatonia, antipsychotics in terms of treatment efficacy, psychosis, and delirium overlap in an individual clozapine is notorious for promoting metabolic patient, prioritizing which symptoms to target can syndrome. While the abscesses themselves could present a diagnostic challenge. Care must be taken have contributed to the development of DKA, there to address the most imminently harmful symptoms is the possibility that loxapine might have also while avoiding exacerbation of the comorbid contributed to the metabolic abnormalities. Our case conditions. Catatonia, delirium, and psychosis each joins one prior case report of DKA developing in a require different therapeutic approaches, with the patient on loxapine. DKA is usually seen in much treatment of one syndrome potentially worsening younger patients, making the case for glucose another. This case report explores some of the intolerance secondary to loxapine more plausible in overlapping clinical features of psychosis, delirium, this patient when considering her age. On the other and catatonia and provides strategies to manage hand, while clozapine is generally associated with these comorbid syndromes in a medically ill patient. weight gain, recent studies on the use of loxapine in autism spectrum disorder have also identified a No. 11 Qualitative Report of Young Adult Cancer Survivors’ reintegration into life activities/roles after treatment Participation in a Mindful Self-Compassion Video completion. Chat Intervention Poster Presenter: Winfield Tan No. 12 Functional Analysis of Schizophrenia Genes Using SUMMARY: GeneAnalytics Program and Integrated Databases Background: Young adult (YA) cancer survivors Poster Presenter: Tharani Sundararajan, M.B.B.S. report substantial distress, social isolation, and body Co-Authors: Merlin G. Butler, M.D., Ph.D., Ann M. image concerns that can result in poor quality of life Manzardo, Ph.D. years after treatment completion. Developing self- compassion may be beneficial for supporting YA SUMMARY: survivors' management of psychosocial challenges Background: Schizophrenia (SCZ) is a chronic (i.e. distress, hardships, and perceived personal debilitating neuropsychiatric disorder with multiple inadequacies) that arise after treatment completion risk factors. Numerous research studies have and impede successful reintegration into life supported the involvement of multiple complex activities and goals. However, a self-compassion genetic components in the causation of intervention, such as Mindful Self-Compassion schizophrenia and other psychiatric disorders. (MSC), an 8-week course that has been empirically Methods: We interrogated clinically relevant and tested with adults, has not been implemented with susceptibility genes associated with SCZ reported in YA survivors and a telehealth modality is essential the literature and genomic databases dedicated to for reaching this geographically dispersed gene discovery for characterization of SCZ. We used population. The purpose of this qualitative study was the commercially available GeneAnalytics computer- to describe themes that emerged from YA cancer based gene analysis program and integrated survivors' participation in an 8-week MSC video-chat databases to characterize an updated master list of intervention. Methods: Nationally recruited 605 SCZ genes and their weighed impact in tissues posttreatment YA survivors (ages 18-29) were and cells, diseases, pathways, biological processes, assigned to one of five video-chat study groups molecular functions, phenotypes and compounds. (N=25) and attended eight weekly 90-minute video- Results: Genes for schizophrenia were chat MSC sessions. Qualitative analysis were predominantly expressed in the cerebellum, cerebral conducted on verbatim transcripts of the recorded cortex, medulla oblongata, thalamus and weekly video-chat sessions for four study groups hypothalamus and associated with other psychiatric/ (n=19); one group did not consent to be recorded. behavioral disorders such as ADHD, bipolar disorder, We utilized descriptive qualitative analysis, in which autism and alcohol dependence. Other associated a solo coder used provisional and descriptive coding non-psychiatric diseases included neuroblastoma, methods and met with research staff to reach colorectal cancer, Alzheimer's and late-onset consensus on the codes and emerging themes. Parkinson's disease, sleep disturbances, impaired co- Results: Descriptive analysis resulted in five ordination, abnormal spatial learning and prevalent themes surrounding participants' cancer inflammation. Functional analysis of the SCZ genes survivorship experiences in the context of learning using the GeneAnalytics program identified MSC. These included non-cancer survivor versus glutaminergic (e.g., GRIA1, GRIN2, GRIK4, GRM5), cancer survivor peer relations, study participant serotonergic (e.g., HTR2A, HTR2C), GABAergic (e.g., social cohesion, body image, trust in health, and GABRA1, GABRB2) and dopaminergic (e.g., DRD1, perceived benefits/challenges of developing MSC . DRD2) receptor genes as well as calcium channel- Conclusion: Further development of MSC related genes (e.g., CACNA1H, CACNA1B), solute interventions for YA survivors that embed transporter genes (e.g., SLC1A1, SLC6A2) and developing self-compassion with aspects of the neurodevelopmental genes (e.g., ADCY1, MEF2C, cancer survivorship experience (body image, peer NOTCH2, SHANK3) involved in major biological relations, trust in health) may support successful pathways and mechanisms associated with SCZ. Conclusion: Our approach to interrogate SCZ genes and their interactions at various levels contributing Schizophrenia (64%) (p<0.001), Bipolar Disorder to disease and pathogenesis should increase our (69%) (p<0.001), Other Psychotic Disorder (75%) knowledge and possibly open new avenues for (p<0.001), Anxiety Disorder (95%) (p<0.001), Opiate therapeutic intervention. We acknowledge the use (76%) (p=0.008), and previously diagnosed support of the NICHD grant (HD02528). hypertension (53%) (p<0.001). 32% of admissions of patients with previously diagnosed type 2 diabetes No. 13 mellitus did not receive metabolic monitoring. Second-Generation Antipsychotic Metabolic Conclusion: There are specific groups that are Monitoring: Are Differences Dependent on Patient particularly at risk of receiving suboptimal rates of Factors? metabolic monitoring while prescribed a SGA, even Poster Presenter: Robert M. Portley, M.D., M.B.A. within an academic inpatient facility. These patients Co-Authors: Stephen McLeod-Bryant, Nicole A. are particularly at risk of not being monitored for Brenson iatrogenic consequences of SGAs. Directing clinical awareness to these groups in particular, and all SUMMARY: patients of SGAs generally, could be a high-yield Background: While there are established guidelines change to current clinical practice that could for monitoring the metabolic side effects of second- improve care and health outcomes for these generation antipsychotic (SGA) medications, clinician patients. adherence with these guidelines remains suboptimal. This retrospective cohort study No. 14 evaluated differences in demographic variables, Patient Perspectives on the Use of Magnetic psychiatric diagnoses, diagnosis of cardiometabolic Resonance Imaging (MRI) for Research Studies in illness, & substance use between patients who did Pregnant Women and did not receive recommended metabolic Poster Presenter: Michelle Zaydlin, B.S. monitoring, to better identify patients particularly at risk of having this component of their care SUMMARY: neglected. Methods: A retrospective chart review Background: There is early evidence that brain included 1,025 unique admissions in one year who structure could change permanently across gestation were discharged from an academic unit at a in ways that promote caretaking behavior. Pre- community-based hospital and prescribed a SGA at /post-pregnancy gray matter volume changes were discharge. For each patient admission, records were recently documented among primiparous mothers in reviewed from 3 months prior to their hospital areas that subserve social cognition—and these admission through their discharge for the following changes predicted postpartum maternal attachment items: weight, height, blood pressure, waist (1). The use of brain magnetic resonance imaging circumference, fasting glucose, fasting lipid panel, (MRI) during pregnancy in future studies could hemoglobin A1c, medical history. Statistical analysis accelerate translation of this knowledge into compared patient-specific factors to whether or not preventive interventions. However, while there are they received laboratory and biometric monitoring no known adverse effects of MRI (without of metabolic parameters recommended for gadolinium) to women or fetuses, brain MRI remains monitoring. Results: This analysis included 1,025 reserved for diagnostic indications in pregnancy (2), admissions prescribed a SGA at discharge (mean age; and patient perceptions are critical to consider. In 43.1, 65% male). 64% of patients had no metabolic this study, we surveyed a convenience sample of monitoring during admission or within the previous pregnant women about their concerns regarding 3 months of their admission, and 25% had participation in a hypothetical research study monitoring results available. 27 patients were involving a brain MRI without gadolinium during discovered to have undiagnosed Diabetes Mellitus pregnancy. Method: Data were collected from a by fasting glucose. Patients who were more likely to larger anonymous survey study on prenatal smoking not to receive metabolic monitoring were black or over a 7-week period (April-June 2017). Participation African-American (72%) (p=0.002), had was offered to all women presenting for obstetric care at 4 clinics across an urban Midwestern severe anxiety symptoms controlled only by academic medical center campus (included privately- combination therapy with benzodiazepines and and publicly-insured patients). Questionnaires venlafaxine. Even more disabling, the patient also presented information in lay language about MRI experienced intractable headache and shoulder pain during pregnancy, then inquired about women's unresponsive to non-steroidal anti-inflammatory willingness to participate in a hypothetical research agents. Given the risk of respiratory depression with study involving MRI during pregnancy his current medications, opioid analgesics were not (yes/no/maybe). Participants who answered 'maybe' favoured. The patient was started on sublingual or 'no' were asked to write what concerns they had buprenorphine at a dose of 8mg three times daily and what, if anything, would increase their with significant improvement. This dose was willingness to participate. The study was exempt maintained and the patient was able to function from IRB review. Results: We collected 76 completed relatively pain-free. Discussion Chronic pain is a questionnaires. Respondents were pregnant women significant complication in patients with TBI and is with a median age of 30-34 from diverse racial and reported by a majority of patients with TBI, ethnic backgrounds (41% non-Hispanic white; 11% regardless of the severity of the injury. The Hispanic; 40% Black; 11% Asian/Pacific Islander). treatment of chronic pain among individuals can be Close to two-thirds (62%) were multiparous and 37% challenging as patients may be on other endorsed lifetime smoking. Regarding willingness to medications. Further treatment with narcotic participate, 28% (n = 21) responded 'yes;' 28% (n = analgesics may therefore increase the risk of 21) answered 'maybe;' and 43% (n = 32) responded respiratory depression. Buprenorphine is a partial 'no.' Narrative responses regarding concerns were mu agonist whose effects plateau at higher doses, at health/safety (38%); time constraints (33%); general which time it begins to act like an antagonist. disinterest (23%), and being in a closed space (5%). Buprenorphine thus has the advantage of effective Receiving more information, knowing that brain MRI analgesia with minimal sedation and may be useful were a "common practice" in pregnant women, and for treating chronic pain among TBI patients already knowing that participation could "help another taking benzodiazepines. While clinicians should be child" were cited as reasons that would persuade aware of these possible benefits, more studies are no/maybe respondents to participate. Conclusion: necessary to evaluate the efficacy of buprenorphine Many pregnant women in this sample would among TBI patients with chronic pain. consider participating in a hypothetical research study involving brain MRI when queried No. 16 anonymously. Focus groups could further elucidate Seeing Double: Sertraline and Diplopia concerns, critical to the design of ethical and Poster Presenter: Adekola Alao, M.D. effective patient education and recruitment materials. Funding. This study was supported by SUMMARY: grant 5K23DA037913 to Dr. Massey from the Introduction Sertraline is an antidepressant in the National Institute on Drug Abuse. Disclosures: None class of selective serotonin reuptake inhibitors to report. (SSRIs), and along with the other SSRIs, it has become a mainstay in the pharmacologic No. 15 management of major depression and related mood Treatment of Chronic Pain With Buprenorphine in a disorders. In this report, we describe a 34-year-old Veteran With Traumatic Brain Injury man who developed diplopia after treatment with Poster Presenter: Adekola Alao, M.D. sertraline. To the best of our knowledge, this is the first reported case of sertraline-induced diplopia. SUMMARY: Case Report A 34-year-old male veteran with a Case Presentation We report a case of a 27-year-old history of PTSD and major depression stabilized on veteran who sustained severe traumatic brain injury citalopram 20 mg daily. Due to a lack of efficacy after (TBI) following a blast injury from an improvised a year, the citalopram dose was gradually titrated explosive device. The patient subsequently suffered down. After one week, the patient was started on sertraline, 50 mg daily. Two days after his first dose believed they were him. Which cause him of sertraline, he started having double vision, as well tremendous discomfort as he became isolative and as light sensitivity. He stopped taking the sertraline, withdrawn on the unit. During meal time he would and these symptoms disappeared. The patient re- go to the dining but would not eat any meals. He challenged himself with sertraline at a lower dose of reported “when I go to sit at my tray, People look at 25 mg daily after 3 days and he had a recurrence of me as if it is not my food, maybe someone else that diplopia as well as blurred vision. Discussion Two looks like me.” Whenever he was told his Vital signs, cases of diplopia after citalopram ingestion have he would say “I not sure that is mine it appears to be been reported in the literature. The acute onset of another patient’s who has my name and diplopia in this patient following sertraline appearance.” Usually pointing to someone else. He treatment, in addition to the rapid resolution of the also reported prior to being in the hospital, he was diplopia and reoccurrence after re-challenge living in an apartment where he was paying his bill indicates an association between this adverse effect consistently until he stopped as he felt like “there and the drug. Although considered very safe, rare was something fishy going on and I started seeing and serious ocular side effects of SSRIs, including other people’s mail/bills coming in my name so I angle-closure glaucoma have been reported. stopped paying the bills” therefore his utilities got Receptors for serotonin have been discovered in the cut off. He also reported he stopped paying rent as eye, strongly suggesting a functional role for this when he went to pay his rent one of the months, the neurotransmitter in ocular tissue. Conclusion lady appeared was someone different and didn’t pay Although further research is needed to establish the after wards leading to his eviction. The patient states cause of sertraline-induced diplopia, this case to one of the nurse on the unit “I saw you on illustrates the importance of increased patient and crutches at the store” and the nurse states he has physician vigilance for this possible adverse effect. never met the pt. before. He also reported seeing his niece at his local bank where and states “she didn’t No. 17 say anything to me, she just walked by.” His son WITHDRAWN claims the niece would not be at the bank as she does not live close to the area. He also told the No. 18 writer, “I saw you the cox cable in my apartment.” “I Saw You Fixing the Cox Cable in My Apartment” He reported symptoms to be intrusive and Fregoli Delusion: A Disorder of Person bothersome. Treatment: The patient was started on Misidentification Haldol 5mg and Titrated up to 10mg twice daily and Poster Presenter: Amarachi Nwaije, M.D., B.S. Benztropine 0.5mg twice daily. The patient underwent a neurological work up, CT scan was SUMMARY: done showed no acute intracranial abnormalities, Mr. B. is a 66-year-old, single, unemployed AA male MRI Brain w/o contrast performed and showed No with PPH of Schizophrenia and Cocaine use disorder acute intracranial infarct or mass effect however in remission and PMH of HTN, who presented to the Volume loss, moderate microangiopathy and old ER for treatment of a laceration he sustained after lacunar infarcts within the right basal ganglia and being hit with an unknown object on forehead. After right periventricular white matter. An EEG done was laceration was treated, He was admitted to the WNL without focal or epileptiform abnormalities. psychiatry. Mr. B. reported symptoms of psychosis Fourteen days into his admission he was given like delusions of Control stating he believed that Haldol Dec 150mg IM. His symptoms gradually people were controlling his bowel movements and started resolving and became less intrusive and urinary frequency leading to multiple bowel bothersome. This case also underscores the need for movements per day and urinary frequency. He also psychiatrists to recognize this disorder, as its initial reported he felt like he was being chocked whenever presentation may appear as if the patient is he ate or drank. He also reported ideas of reference uncooperative/paranoid and disorganized or when he is watching TV. Mr. B. complained of malingering to get out of responsibilities. Also, this “seeing people who look like me” and strongly syndrome ass. with Traumatic Brain Injury. productive life for years and may begin to show signs No. 19 of "psychosis" which can be first detected by the Psychosis and Schizophrenia Spectrum Disorders legal system through problems at work or with Contributing to Legal Problems in Populations 50 family as disorganized behavior may became more and Older apparent. Poster Presenter: Amarachi Nwaije, M.D., B.S. No. 20 SUMMARY: Philadelphia Alternative to Forensic State Ms. A is a 55 y/o African American female with No Hospitalization Model: Evaluation Based on Public- past psychiatric history and past medical history of Academic Partnership asthma. She was transferred to our hospital from jail Poster Presenter: Christina D. Kang-Yi, Ph.D. for competency evaluation. Ms. A reports because Co-Authors: Christy L. Giallella, Ph.D., Katie M. she was arrested after she appeared at her previous Nikolajuk, Na Young Kim, Jac Rivers, Katy M. Kaplan, place of employment and violated a restraining Ph.D., Aelesia E. Pisciella, Ph.D., Shakira Williams, order. She denied any other legal history. She M.B.A., Trevor R. Hadley, Ph.D., David S. Mandell, reports she was fired from job due to "bad conduct, Sc.D. low performance, inappropriate behavior, Ideations and signs of paranoia". Ms. A presented with SUMMARY: commentary auditory hallucinations, Pt reports that Unreasonable wait time for forensic treatment for her previous place of employment believed "she was competency restoration has been a great concern an informant, leaking information to Capitol Hill" and across the United States. These prolonged wait times that she hears the voices of her managers and the are costly due to the additional cost of care for IST "investigators" at her former job continuously inmates while they await inpatient treatment and speaking to her. Thought insertion and broadcasting, legal actions due to unreasonable wait time for She was fixated on "investigators" who installed a inpatient transfer. The lack of systematic "mind control" on her without her permission for coordination and monitoring of the incompetent to "surveillance." She denied depressive or manic stand trial (IST) cases has resulted in unreasonable symptoms. Treatment: Routine labs were drawn. Pt wait time for forensic treatment for competency was worked up to r/o other causes of psychosis and restoration, lack of competency restoration and lack Trazadone 50mg was started the first day. After labs of recovery-oriented community treatment designed were returned Ms. A was started on Risperdal 1mg for those who cannot be restored to competency. BID. It was titrated up to Risperdal 2mg QAM and The wait time for inpatient forensic treatment in 3mg QPM, and Cogentin 1mg BID was added. Clinical Philadelphia is at the longer end of these national Diagnosis: A provisional diagnosis of Unspecified trends. To improve efficiency of competency Psychosis was made at Admission, after observation, restoration and recovery-oriented community she was given a diagnosis of Schizophrenia Late psychiatric care for individuals with IST, Onset After labs results ruled out primary causes. Philadelphia's Department of Behavioral Health Current literature classify Late Onset Psychosis(LOP) designed the Philadelphia Alternative to Forensic as ages 40 to 59 and Very late Onset Psychosis State Hospitalization Model. This program will: (1) (VLOP) >60 yrs. old. In patients with onset at age 45 identify facilitators and barriers to improving the years or later, visual, tactile, and olfactory efficiency of current IST case management practice; hallucinations, third-person running commentary and (2) improve recovery-oriented community auditory hallucinations, and paranoid and partition psychiatric treatment for individuals with IST being delusions have been reported to be predominant discharged from a state hospital forensic care unit. symptoms, and negative symptoms such as affective The City Philadelphia Department of Behavioral flattening and formal thought disorder are less Health and Intellectual Disability Services, common. This report serves to increase our Community Behavioral Health and the University of awareness of growing population of psychosis Pennsylvania Center for Mental Health Policy and people who would have appeared to have Services Research have partnered to estimate the impact of the Philadelphia Alternative to Forensic with particular emphasis on the legal and ethical State Hospitalization Model on efficiency of IST issues surrounding EAS is discussed. forensic care coordination and recovery-oriented community psychiatric treatment for individuals with No. 22 IST discharged from the state hospital forensic care The Making of ADHD Nation unit. This poster presentation introduces the Poster Presenter: Saeed Ahmed, M.D. partnership-based evaluation formation and Co-Author: Sanya Virani process. The processes of the program evaluation has led the public-academic partners to learn the SUMMARY: importance of (1) facilitating communication This is a case of a 25-year-old male, high school between clinical and research/evaluation teams, graduate, “Mr. A.” brought into Psychiatric systems of care such as the behavioral health emergency presented unkempt, anxious, and a bit system, the jail system and community service hostile, psychotic with paranoid delusions and providers; and (2) designing creative ways of auditory-visual hallucinations. After abandoning his encouraging service providers to collect good quality car somewhere, he had gone missing, and of primary data and utilize the data for service exasperated family members filed a missing person improvement. The presentation will introduce how complaint. Two days of mysterious absence returned evaluation process has informed and address future to his family, declaiming God had ordered him “to go directions for public-academic partnership to further to Brooklyn Navy Yard to join MI-6,” the British forensic behavioral health services for people Intelligence Agency, and that he had immediately entering jail with psychiatric disorders. taken the subway there. The brief but bizarre proclamations emanating from their son shocked his No. 21 parents because ideas such as these had never come Euthanasia and Physician-Assisted Suicide: A from him. Mr. A. thwarted our initial attempts to talk Forensic Psychiatric Perspective with him by simply nodding his head when we Poster Presenter: Zain Khalid, M.D. provided the option to talk later. The following day, he broke down and was inconsolable. As his hands SUMMARY: quivered and he fidgeted in his chair, he slurred, “I Euthanasia and physician assisted suicide (EAS) want to quit. . I tried but I couldn’t. . . I am ashamed remain subjects of heated controversy among of myself.” He mumbled, “Adderall.” Mr. A. admitted physicians, patients and the general public. Even as first experimenting with the drug during high school, efforts toward legalization in the US and abroad after being introduced to this “smart pill” by his have made recent gains, ethical issues of autonomy, friends, who often took it to excel in classes. His few- dignity, professional obligations and integrity, times-a-month dosing gave way to a few-times-per- protection of vulnerable patient populations week, until he became fully addicted, and was using including the mentally ill, and concerns about it to get high. Chasing the dragon of his addiction, potential for abuse and 'slippery slopes' continue to and anxious he would run out of pills, he sought it divide opinion. This review summarizes these ethical from friends and sometimes the streets. The source concerns in the context of relevant landmark cases did not matter; Mr. A. went so far as to feign illness, and recent legislative efforts in the US and abroad. It by researching and mimicking the Attention also comments on the expanding role of forensic deficit/hyperactivity disorder (ADHD) symptoms and psychiatrists, particularly in establishing robust present himself as a textbook case of ADHD to a standards of competence to consent for EAS, and in psychiatrist to secure a renewable prescription. The otherwise facilitating the decision making process. case of Mr. A. illustrates six troubling issues Evolving attitudes and practices among psychiatrists, associated with prescribing Psychostimulant Drugs, professional organizations and the general public are misdiagnosis, inappropriate stimulant prescription, also considered. Finally, an emerging need for the resulting addiction, untoward side effects, greater training of psychiatrists in end of life issues, serious social consequences, and, when the numbers are extrapolated, an increased economic burden. What should be extremely crucial is for clinicians to frequently found in over-the-counter cold and cough conduct a thorough evaluation before making the medication, pharmacologically active as an isomer of appropriate, non-pressured, correct diagnosis, or codeine, utilized for cough suppression. At even considering prescribing a medication as a first supratherapeutic dosages it acts as a nonselective resort. It is simple: understanding the disorder and serotonin reuptake inhibitor, a sigma-1 receptor constructing the appropriate diagnosis should target, agonist, and a NMDA receptor antagonist, resulting as a rule, the appropriate treatment. in dissociative and stimulant effects at higher doses (>240 mg). At high doses of DXM produce PCP-like No. 23 behavioral effects much similar to the state of "drug- A Case of Huntington’s Disease With induced psychosis". DXM hold the potential for Neuropsychiatric Complications abuse, also used as the recreational drug, commonly Poster Presenter: Saeed Ahmed, M.D. known with street names as Red Devils, CCC, triple c, robo, skittles, and poor man's PCP. We present a SUMMARY: case report of a middle age medical professional, Huntington’s disease (HD) is an autosomal dominant with a prior diagnosis of bipolar disorder, who neurodegenerative disorder which is manifested presented in an acutely manic state, precipitated by with cognitive, motor and severe Neuropsychiatric over-utilization of DMX. The case is novel in the manifestations commonly anxiety, irritability, literature in that the stated purpose of using dysphoria, agitation, depression, obsession and excessive amounts of DMX was to purposely self- compulsions, and psychosis. Estimates of the medicate mood symptoms and titrate dosages with prevalence of neuropsychiatric symptoms in DMX to achieve and maintain a 'functional' Huntington’s disease are between 33 to 76 percent hypomanic state. Published literature and evidence of patients. Historically neuropsychiatric illness in shows that Psychoactive symptoms are dose related Huntington’s disease, we do not have any clear and symptoms range from intense anxiety, cognitive guidelines or protocol, there are many available impairment, insomnia, paranoia, delusional beliefs, options but due to adverse of medications like the extreme agitation, visual and auditory hallucinations, risk of depression and suicidality make it more and euphoria. This unusual case illustrates diagnostic complicated to use these medicines. We present a and treatment challenges, clinical implications of case of the 42-year-old white female, single, abuse of over-the-counter cough syrup DXM, homeless, with past medical history of Huntington’s particularly in a patient with prior history of Bipolar Disease, progressive dementia secondary to Disorder. Huntington’s Disease, Seizure Disorder. She has an extensive Psychiatric history of polysubstance abuse No. 25 disorder, Major Depressive Disorder, and Borderline Understanding Gut Fermentation Syndrome in the Personality Disorder. She has a prior history of more Psychiatric Evaluation of Patients With Suspected than 30 hospitalizations, multiple suicide attempts, Alcohol Use Disorder admitted to Psychiatry service for active suicidal Poster Presenter: Jacob R. Wardyn ideations with serious intention and planned to overdose on Heroin. This case study is novel in the SUMMARY: literature; we discuss the clinical challenges faced by Gut Fermentation Syndrome, also known as auto- clinicians while managing such cases in the absence brewery syndrome, is phenomenon not well of clear guidelines. understood in today's medicine with few articles discussing its etiology, presentation, diagnosis, and No. 24 treatment. The literature describes Gut Dextromethorphan (DMX)-Induced Mania Fermentation Syndrome as patients becoming Poster Presenter: Saeed Ahmed, M.D. intoxicated without the ingestion of alcohol. The hypothesized mechanism is from overgrowth of SUMMARY: certain yeast in the gut that allows for fermentation Dextromethorphan (DMX) is an ingredient of complex carbohydrates, especially after high carbohydrate meals. This creates an interesting months (may include "psych cinema", Q&A sessions dilemma for doctors when beginning evaluation of with seniors or attendings on topics of interest, and patients with alcohol use disorder as this rare other educational activities). Surveys will be syndrome could be used as a defense for a patient's developed in RedCap and administered before and apparent alcohol use. As was recently seen on our after each monthly event, and participants will be psychiatry consult service, the patient stated an asked to indicate which prior events they attended. abstinence from alcohol use and that auto-brewery The data from the surveys will be analyzed using syndrome was the cause of the continually elevated statistical software. Expected Results: A preliminary blood alcohol levels. Therefore, it is paramount to survey was developed and key assessment domains know the typical presentation seen, the possible will be presented. An increase in interest amongst diagnostic studies available, and typical effective medical students after their attendance of monthly treatment when presented with this clinical events over the course of 6 months is expected. scenario. Having this understanding would allow for Conclusion: Events that are co-developed with and the psychiatrists involved to give a more thorough conducted within a Psychiatry interest group can be recommendation. a useful career recruitment method. Event surveys will help tailor the program to better suit the No. 26 interests of medical students. As interest in Developing Interest in Psychiatry Careers Among Psychiatry among medical students rises, more Medical Students students will apply for Psychiatry residency Poster Presenter: Simran Brar, M.D. programs and help address pressing workforce Co-Authors: Kanakadurga Meyyazhagan, M.D., issues. Glenda L. Wrenn, M.D., M.S.H.P. No. 27 SUMMARY: “I Will Kill Myself… If You Discharge Me!” Introduction: The shortage of Psychiatrists in the Complexities in Clinician Decision Making in a Case United States continues to be a problem especially of Suspected Conscious Simulation within urban underserved and rural communities. Poster Presenter: Catalina Trevino Saenz, M.D. Over 50% of Psychiatrists in the Georgia are Co-Authors: Sina Shah-Hosseini, M.D., M.S.E., Raj currently over the age of 55. In addition about 26% Addepalli of the psychiatric residency slots in 2015 were filled by international medical graduates; who often help SUMMARY: address population disparities by practicing in This is a case of a 42 year old Hispanic male with past shortage areas. Although the American Association psychiatric history of self-reported depressed mood of Directors of Psychiatry Residency Training and suicidal ideation and multiple inpatient (AADPRT) Recruitment Committee is charged with admissions for similar complaints who presented to promotion of psychiatry careers, little empirical the Psychiatric Emergency Service complaining of evidence exists on effective strategies to increase command auditory hallucinations to kill himself. He U.S. medical student interest in the field of reported conditional suicidal ideation and made a Psychiatry. The goal of this project is to learn which suicidal gesture to hang himself in the context of medical school based events have greater impact on imminent discharge from the Emergency room. The medical students' interest in Psychiatry. Methods: In patient reported history of daily cocaine use last use the proposed study, researchers will work with one month prior to hospital arrival, history of Morehouse SOM medical students who are currently incarceration for 16 years and non-adherence to voluntarily participating in the Morehouse home psychiatric medication which included an 'Psychiatry Interest Group' to better assess medical antipsychotic. Upon admission to the inpatient unit student interest in the field of Psychiatry and co- the patient was restarted on home medications and design activities to promote interest. The researcher presenting symptoms had resolved within hours of team will meet with the Psychiatry Interest Group his initial evaluation. Once resolution of symptoms who will host monthly events over the course of six was sustained for three consecutive days and medication compliance was maintained, patient am I looking for? • Location, location, location: again expressed conditional suicidal ideation in the Geography and where I search is as important as context of his imminent discharge from the inpatient much as my practice and colleagues. • unit. Review of the psychiatric history indicated that Compensation packages: MGMA & my colleagues he was last discharged from the inpatient psychiatric can assist me in finding the best package, loan unit 8 days prior to current admission. Patient had a repayment, sign-on other benefits. • The site visit & history of multiple psychiatric inpatient admissions key questions I need to ask: Asking the right resulting from nearly identical presentation. Contact questions, finding the right answers. • The Contract: with his outpatient treatment providers indicated What to look for and when to be cautious. • Move & difficulty in addressing the veracity of his suicidal relocation questions: Asking all the right questions to threats and subsequent referral to the Emergency avoid confusion and disappointment. • Finding a room to address his threats. Subsequent testing on mentor: Key to success in finding a mentor, what to the MMPI-2 inventory and M-FAST (Miller Forensic look for and how to find. • Starting my career: All the Assessment Test) revealed a profile highly suggestive ingredients to starting my career, life, family and all of malingering. He endorsed extreme symptoms, the rest. rare combination of symptoms, unusual hallucination, unusual symptom course, and No. 29 demonstrated suggestibility to unusual items. This Family-Centered ECT Care case highlights the default in discerning the true Poster Presenter: M. Justin Coffey, M.D. intentions of patients who consciously feign their Co-Authors: Kristina Bullard, M.S.N., R.N., C. Edward symptoms especially of a suicidal nature and Coffey, M.D. subsequently result in inpatient admissions which use up valuable inpatient beds and tie up scarce SUMMARY: mental health resources. Absence of a reliable tool In 2001 with the publication of its groundbreaking to accurately assess seriousness of suicidal gestures report Crossing the Quality Chasm, the Institute of and intent leads to hesitation on part of clinicians to Medicine (IOM) issued a clarion call for health care discharge patients who may not require inpatient to be centered on the patient. We began using its admission and also lead to counter transference of "10 Simple Rules" as a roadmap for transforming the treatment providers in addressing the actual needs care of his ECT Service at a major teaching hospital. of these patients. Medicolegal implications of A key strategy in this transformation was to partner ignoring suicidal threats and gestures which may with patients and their families in the design and lead to inadvertent accidental suicide need to be assessment of the ECT care. This strategy included considered. Long term engagement of these patients routinely providing our patients the option to be will be needed to effectively address their intentions accompanied by family members and significant of illness feigning behavior. others into the ECT treatment suite to observe and participate in the procedure (from preop to No. 28 treatment to recovery). Over the next decade we Life After Residency: Making the Next Move refined this patient-centered approach and learned a Poster Presenter: Kevin Malee great deal from its application to ECT care. During this time, nearly all patients preferred to have a SUMMARY: family member or significant other in the ECT • Creating the attractive CV & how best to present treatment suite during one or more procedures. The yourself on paper: First impressions are key and your lessons learned from the focus group followed five CV will tell others about you and what you have key themes. First, the presence of family members in accomplished. • Where to begin my career search: the ECT treatment suite relieved anxiety for both the Recruiters, agencies, federal & state program all can patient and family members and strengthened their assist, but I must know where I want to begin. • trust of the ECT team. Second, participating in the Searching for the right practice: Traditional, primary ECT treatment enhanced family members' overall care or hospital medicine - how to decide and what engagement in the patient's mental health care. Third, participating in the ECT treatment empowered Methods: Demographic data was gathered about the family members to improve both pre-ECT care (e.g., clinic’s patient population by analyzing its patient ensuring adequate hydration for more comfortable database. The NKI Agency/Program Assessment Tool venipuncture) and post-ECT care (e.g., assisting in was conducted with 27 senior staff members to post-ictal reorientation). Fourth, the presence of assess the CC of the clinic at an organizational level. family members in the ECT treatment suite The Iowa Questionnaire was conducted amongst 200 enhanced communication among providers (e.g. patients to assess their perception of CC. Provider- between the psychiatrist and the anesthesiologist). level questionnaires were conducted to assess the And fifth, participating in the ECT treatment CC of providers themselves. Structured interviews empowered family members to serve as were conducted with 25 clinicians focusing on the ambassadors against stigma. As these lessons have clinic’s histories, and the perceived barriers to and been shared, several institutions have adopted and strategies adopted to increase CC. Results: Clinic implemented this family-centered approach to ECT demographics revealed a female majority (62.5%) care. Based on these incredibly positive experiences, with self-identified race and ethnic categories we offer this poster presentation to IPS attendees composed of 44% Hispanic, 25% Asian, 12% Non- and encourage them to engage their ECT patients in Hispanic White and 6% Non-Hispanic Black. NKI scale a conversation about how family members or revealed organizational strengths including matching significant others might become involved in ECT care culturally and linguistic trained staff to its patient processes. population, while areas of improvement included a lack of such staff in administration. The Iowa No. 30 Questionnaire results included patient satisfaction Pursuing Cultural Competence at the Organizational with the availability of staff who understood their and Clinical Levels: A System-Based Model Applied cultural background, while some patients felt there to a Community Center in NYC could be a higher level of community outreach from Poster Presenter: Pamela C. Montano, M.D. the clinic. Provider questionnaires revealed a Co-Authors: Xiaojue Hu, M.D., Hunter L. McQuistion, heterogeneous level of CC among staff, with higher M.D., Diana Chen, Ph.D., Giselle Plata, M.P.H., Diana levels of CC with staff affiliated with ABC and LBC. Acosta, M.D., Dustin Chien, L.M.S.W. Interviews with staff elucidated such clinical barriers to care as a high stigma against mental health and a SUMMARY: tendency to present psychiatric symptoms initially to Introduction: In a globalized world, the development non-psychiatric providers in both the Chinese and of culturally responsive care in mental health Latino populations. Structural barriers included treatment is vital. Examples of the implementation challenges in developing cohesion among staff with of culturally competent care in diverse community heterogeneous cultural backgrounds. Strategies settings are lacking in the literature. Examples of adapted to increase CC care included close barriers to implementing such care and their coordination between staff and family, between potential solutions have also not been widely staff and community and agencies, and between discussed. As an urban outpatient community clinic staff members and the administration. Discussion: situated in the multicultural Lower East Side The clinic has strengths in such areas of CC as having neighborhood in New York City, Gouverneur staff whose cultural and linguistic backgrounds Behavioral Health is an example of a place where match those of the prevalent client groups, as well culturally competent care was developed and as on the emphasis in forging relationships amongst implemented before such terms were defined. It patients, staff, and organizations. Areas of contains two sub-clinics – the Asian Bicultural Clinic improvement include paying attention to other (ABC) and Latino Bicultural Clinic (LBC) – that has demographic information (such as the LGBT adapted treatment to its diverse clientele. This community), the integration of the ethnic sub-clinics project assesses the cultural competence (CC) of the within the clinic as a whole, and improvement of entire clinic on multiple levels, focusing on cultural training for all staff. Cultural competence is a examining strengths and areas of improvement. process, not a definite end point. Improvement requires the on-going evaluation and monitoring of October 2016 and established a technical assistance services on multiple levels to ensure an equality of team to ensure quality. Implementation challenges access and quality of treatment for the populations have included lack of community knowledge about we’re dedicated to serve. the availability and rationale for OnTrackNY services. NYS's technical assistance framework facilitates the Rapid-Fire Talks adoption of strategies for increasing the number of a team's community connections and referrals Thursday, October 19, 2017 received. Results: In October 2016, 17 OnTrackNY teams were open to referrals, each with an ORC. Rapid-Fire Talks: Focus on Community New ORCs receive biweekly individual consultation Collaboration calls for three months, followed by monthly individual and learning collaborative calls to enhance No. 1 skills in linkage to and tracking of referral sources, in Connecting Coordinated Specialty Care Teams for addition to building engagement and evaluation the Treatment of First-Episode Psychosis With Their skills. OnTrackNY teams have received 1,206 Communities referrals since July 2015 and enrolled 273 clients. Presenter: Iruma Bello, Ph.D. Referrals came from varied sources, with 22% from a Co-Authors: Liza Watkins, L.M.S.W., Lisa B. Dixon mental health outpatient provider, 41% from inpatient units, and 23% self-referred or referred by EDUCATIONAL OBJECTIVE: a family member. An additional three percent came At the conclusion of this session, the participant from community organizations and emergency should be able to: 1) Discuss implementation rooms, with one percent coming from schools. The challenges and strategies for integrating coordinated average time from the onset of psychosis to specialty care services into the mental health enrollment was 7.4 months. Conclusion: OnTrackNY spectrum of services and community; 2) Understand ORCs demonstrate an ability to establish community strategies for training providers to conduct outreach relationships and facilitate the early identification and recruitment activities to enhance access to the and referral of young people experiencing psychosis. service; and 3) Describe key methods for monitoring However, a preponderance of OnTrackNY referrals the quality of team outreach activities. still come from inpatient units, and the time from development of symptoms to CSC treatment SUMMARY: remains over seven months. Challenges in Background: Coordinated specialty care (CSC) is a establishing a diverse network vary by host setting multi-element, multidisciplinary team-based model and community, and clinicians are often new to now considered the evidence-based approach for conducting outreach. As such, individual and group individuals experiencing early psychosis. Given that consultation over time is needed so that new CSC shorter duration of untreated psychosis is associated programs can become flexible and responsive to the with better outcomes, one of the challenges in CSC community's needs and reduce delays in connecting implementation efforts has been optimizing a to optimal treatment. referral pathway. OnTrackNY is New York State's CSC program. Objective: We will describe the expansion No. 2 of CSC services in New York State (NYS) and how Recovery From Serious Mental Illness Through a OnTrackNY teams build community connections to Novel Mobile Community Navigation Program: optimize the referral pathway. We will also describe “Opening Doors to Recovery” the framework for training and monitoring outreach Presenter: Luca Pauselli, M.D. and recruitment coordinators (ORC), who conduct Lead Author: Michael T. Compton, M.D., M.P.H. outreach to potential referral sources, rapidly Co-Author: Beth Broussard process referrals, and evaluate clients for eligibility. Methods: The NYS Office of Mental Health expanded EDUCATIONAL OBJECTIVE: from four CSC programs in late 2013 to 18 by At the conclusion of this session, the participant should be able to: 1) Define the opening doors to supported by a CMS TCPi grant. LSU Health Baton recovery (ODR) model; 2) Describe the importance Rouge, a division of Our Lady of the Lake Hospital, of community navigation to recovery support; and 3) comprises five primary care clinics staffed by 17 List two types of community partnerships that make faculty physicians, 40 residents, and nine nurse mobile delivery of the ODR model possible. practitioners seeing over 31,000 patients annually. The Mid-City Clinic, the pilot site, sees over 10,000 SUMMARY: patients annually, with about 980 patients Part of Rapid-Fire Talks: Focus on Community maintaining a diagnosis of depression and/or Collaboration anxiety, though many cases may go unrecognized. The authors present the first in a series of "how-to" No. 3 presentations addressing the real-world challenges How to Start a Collaborative Care Program in an of creating, maintaining, and growing a collaborative Academic Primary Care System: Vision, Resources, care program in an academic hospital-based primary Business Plan, and Early Experience care clinic system. This first presentation covers the Presenter: L. Lee Tynes, M.D., Ph.D. authors' initial exploratory and organizational Co-Authors: Angela Gourney, R.N., Katherine Taylor, sessions, initial conceptualization and creation of the L.C.S.W., Alvin F. Smith, L.C.S.W., Brandon Michel, vision, resources felt to be most helpful, and the M.D. steps to create a business plan. The planning steps for ramping up the behavioral health workforce and EDUCATIONAL OBJECTIVE: the associated training will be reviewed. The At the conclusion of this session, the participant education of non-program clinicians will also be should be able to: 1) Identify the multidisciplinary presented. Baseline (pre-implementation) data leadership cast that should create and organize collection will be detailed, along with the process to around the vision for an integrated care program in determine workflow. The authors conclude with a an academic environment; 2) Appreciate the initial reflection on early experiences, the roll-out process, resources required for planning such an integrated lessons learned, and preliminary descriptive data. care program; 3) Enumerate the essential aspects of a business plan to create the program; and 4) Friday, October 20, 2017 Understand the initial steps in a rollout of a collaborative care program. Rapid-Fire Talks: Focus on Early Childhood Interventions SUMMARY: Integrated care programs have recently received No. 1 much publicity owing to their potential to address Moving Upstream in a Coordinated Care depression and other mental health problems within Organization: Incorporating ACEs the primary care setting, bringing improved Presenter: Maggie Bennington-Davis, M.D., M.M.M. psychiatric outcomes, reduced health care expenditures, and higher patient and provider EDUCATIONAL OBJECTIVE: satisfaction. Sophisticated research programs bring At the conclusion of this session, the participant resources and expertise to the participating primary should be able to: 1) Learn how studying high care practices not commonly available to most clinic utilization of health care is related to upstream and systems, though a growing number of web-based early life factors; 2) Translate maternal and early and didactic resources are available to interested childhood experiences into health services; and 3) parties. Examples include the AIMS center Consider integration as primary and secondary (https://aims.uw.edu), SAMHSA programs prevention. (www.integration.samhsa.gov), support materials from the COMPASS multisite study (COMPASS SUMMARY: Toolkit 2015), recent texts (Raney, 2015), and the Health Share of Oregon is one of Oregon's APA-sponsored training in integrated care, coordinated care organizations, which coordinates mental health, substance use disorder (SUD) Co-Authors: Matthew Biel, Elise Fallucco, Leandra treatment, oral health, and physical health services Godoy, Melissa Middleton, Anna Kelley for over 200,000 Medicaid members. In studying high utilization of health services, Health Share EDUCATIONAL OBJECTIVE: conducted a life experiences survey, which showed At the conclusion of this session, the participant that early childhood experiences translated into later should be able to: 1) Describe the rationale for adult adverse experiences, chronic illness, SUD, and increasing attention to early childhood mental high health care needs and costs. High adverse health in the primary care setting; 2) Recognize the childhood experiences (ACEs) have long been linked range of early childhood mental health consultation to "health behaviors" having specific biological risks approaches in pediatric primary care; and 3) for disease--such as tobacco or injection drug use or Describe the common barriers related to access to lung or liver disease--but high ACEs have also been early childhood mental health services. shown to have social consequences with their own health impacts. Increased rates of high school non- SUMMARY: graduation, incarceration, and homelessness are all Objective: Present three models of early childhood associated with increased ACEs. Other risks to social mental health collaborative care in pediatric primary function linked to ACEs include problematic care. Background: Collaborative approaches to kindergarten behavior, literacy, and academic primary care offer the opportunity of early performance; teen pregnancy and associated family, identification, improved access, and higher quality financial, job, stress, and anger problems; and sexual care. Collaboration focused on very young children victimization in adulthood. Understanding what else (0-5 years old) offers the earliest possible beyond ACEs happens to people as they grow into opportunities for identification and intervention, adulthood and where social as well as clinical with substantial potential for preventive mental interventions may change a life trajectory is key in health, early identification, and improved access to addressing the population health consequences of specialty services when needed. However, few early adversity. Health Share subsequently invested pediatric primary care providers (PCPs) are in "upstream" services that could assess for and comfortable with these issues. Strikingly, studies of address social determinants of health and integrate the most prominent pediatric consultation models mental health, SUD treatment, and primary health report few consults focused on young children, who care in maternal and early childhood programs. represent a high proportion of pediatric visits. Young These programs include ensuring access to effective children need developmentally specific collaborative contraception, screening for social risk factors in care. Methods: This presentation will describe the pregnant women, using a specific approach in development of three models of collaborative early collaboration with the Department of Human childhood mental health (ECMH) care in pediatric Services for substance-dependent pregnant women, medical homes. Results: We will present a needs collaborating with community-based programs to assessment in an urban area from which two ensure kindergarten readiness, and the development innovative models of identified gaps were developed of foster child medical homes. All of these programs in an urban setting. In this urban area, 100% of rely on the integration of mental health, substance respondents (N=50) endorsed high levels of unmet use treatment, and primary care in order to need, and 79% reported low comfort and knowledge adequately prevent the impact of adverse related to ECMH. From these findings, two models experiences. Each of these programs will be briefly were developed: 1) mobilization of a citywide child described during this rapid-fire talk. psychiatry access program focused on ECMH and 2) a colocated ECMH team to serve families with young No. 2 children. We will present an established model of Innovation in Early Intervention: Collaborative screening promotion in pediatric primary care. The Approaches to Early Childhood Mental Health in model employs didactics and clinical consultation to Pediatrics support PCPs. After a six-month pilot, 70% of Presenter: Mary Margaret Gleason, M.D. providers reported screening at most well child visits (versus four percent at baseline; p=0.0001), and evaluation and treatment. In some, referral is not billing claims data showed similar patterns (0.1% to even possible, as there are no practicing child 32.3%, p=0.0001). To address PCP concerns about psychiatrists nearby. Pediatric residency presents an time required for screening, efforts to shorten the opportunity during a critical period of learning and screening measure while maintaining validity professional development during which pediatric resulted in a screen with 89% sensitivity and 85% interns can be prepared and primed to provide basic specificity predicting psychiatric diagnosis. We will mental health assessments and, when appropriate, present an interdisciplinary consultation model for to initiate treatment. Academic centers often house children 0-5 that offers onsite consultation, phone both pediatrics and psychiatry training programs; consultation, and remote consultation to PCPs in however, interdisciplinary collaboration is not as academic and community settings. The central commonplace as the population needs demand. principles of the model include a strength-based Through collaboration with pediatric colleagues, approach, modified common factors, effective particularly during pediatric residency training, child communication skills, and emphasis on accessible, psychiatry faculty have the opportunity to broaden concrete information for families. Compared to their influence and to help address mental health baseline, at one year, active providers had more disparities, albeit indirectly. Demands on the time of comfort managing ECMH issues (p<0.005) and higher faculty, particularly if faculty are volunteer or part- frequency using ECMH approaches (p<0.05). time, and funding limitations can be perceived Conclusion: Each model of integrated care offers barriers to the development and implementation of developmentally specific, innovative approaches to such educational programming. By leveraging promote ECMH, shaped by the needs of the strategic alliances with community partners and community. Pediatric primary care presents an ideal using technology to increase the efficiency of face- setting in which to identify and address ECMH and to-face time and manage communication with caregiver concerns that have lasting effects. rotation sites, trans-discipline mini rotations can be achieved with relative ease. In this presentation, the No. 3 creation and ongoing development of a child Development of a Psychiatry Mini-Rotation for psychiatry mini rotation directed by a part-time child Pediatric Interns psychiatry faculty member with a secondary Presenter: Sarah Y. Vinson, M.D. appointment in pediatrics will be discussed.

EDUCATIONAL OBJECTIVE: Rapid-Fire Talks: Focus on New Models of Care At the conclusion of this session, the participant should be able to: 1) Review the rationale for child No. 1 psychiatrist involvement in pediatric resident Cutting-Edge Telepsychiatyy: Tele-Teaming, Store education; 2) Discuss the development of a and Forward, and In-Home Care psychiatry mini rotation for pediatric interns at Presenter: Jay H. Shore, M.D., M.P.H. Morehouse School of Medicine; and 3) Identify ways in which technology can be leveraged to maximize EDUCATIONAL OBJECTIVE: the time of part-time and volunteer faculty. At the conclusion of this session, the participant should be able to: 1) Learn about evolving models of SUMMARY: care that involve telepsychiatry—live interactive With high demand for the treatment of child mental videoconferencing; 2) Examine how telepsychiatry illness and a pronounced shortage of child can be used to blend care teams between and within psychiatrists, pediatricians are frequently met with sites of care; 3) Become familiar with the concept, mental health chief complaints. In fact, mental workflow, and design of store and forward health conditions are among the most common telepsychiatry; and 4) Understand how chronic medical conditions treated by general telepsychiatry can provide care directly into a pediatricians. In many areas of the country, referral patient’s home. to specialty services may result in delays in of providers, including the patient's primary care SUMMARY: provider, a care manager and a psychiatric Live interactive videoconferencing in psychiatric consultant, work together to provide mental health care—telepsychiatry—is a rapidly expanding model care. This session will discuss the evidence base and of care that increases access and quality of care to core principles of Collaborative Care. The business patients. Telepsychiatry is not only helping innovate case and new payment options for Collaborative the locations where treatment is received but also Care will also be reviewed. the structure and models of treatment being delivered. This talk will review and describe three No. 3 evolving models of psychiatric care: tele-teaming, An Overview of the Project ECHO Model for Child store and forward telepsychiatry, and in-home and Adolescent Mental Health telepsychiatry. Tele-teaming involves creating teams Presenter: Steven Adelsheim, M.D. of care between and within locations of care, blending virtual and in-person interactions to enable EDUCATIONAL OBJECTIVE: team-based care. Tele-teaming will be illustrated At the conclusion of this session, the participant with examples drawn from residential alcohol should be able to: 1) Name three components of the treatment and integrated care. Store and forward ECHO model; 2) Understand multiple settings in telepsychiatry is a system that allows asynchronous which the ECHO model might best apply for their patient data capture to facilitate asynchronous community; and 3) Consider strategies for psychiatric consultation. Telepsychiatry has been addressing some of their local challenges in increasing care directly provided to patients in their implementing ECHO model programs. homes with a range of mental health treatments. After presenting the three models, the talk will SUMMARY: conclude with an examination of how telepsychiatry We know that half of all mental health conditions in general can shift models of care delivery to begin by age 14, and three-quarters by the age of 24. improve access and quality and address cost and While 20% of adolescents may face a mental health value for the health care system. diagnosis, 79% of this group ultimately don't access care. At the same time, the national shortage of No. 2 child and adolescent psychiatrists and mental health Collaborative Care: Evidence-Based Mental Health providers continues across the United States. for Primary Care Settings Unfortunately, the need for expanded support for Presenter: Anna Ratzliff, M.D., Ph.D. those in schools, primary care, and other community settings in addressing the mental health needs of EDUCATIONAL OBJECTIVE: children, youth, and their family appears to be At the conclusion of this session, the participant increasing. Project ECHO is an innovative model that should be able to: 1) List the Collaborative Care shows great potential by increasing the capacity for principles; 2) Describe the evidence-based for partners in health and educational settings to Collaborative Care; and 3) Name the key points of recognize the mental health needs of young people the business case for Collaborative Care. in their communities and link them to early supports. Through the learning loops of the ECHO model, SUMMARY: participants can present patients from their Faced with national shortages of mental health community settings to a multidisciplinary team of professionals, communities need new ways to experts and their regional partners to receive deliver effective mental health care. Psychiatrists are guidance and support in how to best provide in a unique position to help shape mental health treatment to those in their home setting. Through care delivery in the current rapidly evolving the interactive discussion process, all participants healthcare reform landscape using integrated care gain knowledge, experience, and confidence in approaches, in which mental health is delivered in managing patients with similar clinical issues. For the primary care settings. In Collaborative Care, a team provider or professional working in isolation, knowing that the ECHO team is available for support should be able to: 1) Demonstrate the knowledge allows for increasing comfort in initially addressing needed to create instant access to care in a the individual child's needs, with the knowledge that manmade disaster; 2) Understand the absolute need backup support and consultation are readily to address culture in a care delivery system; and 3) available. With the support of the ECHO team, local Address the needs of a clinical support team as it providers progressively learn how to manage more responds to a disaster. complex clinical situations, increasing the local capacity for effective treatment. This presentation SUMMARY: will focus on examples of the use of the ECHO model On June 17, 2015, a self-avowed white supremacist to support young people in primary care and joined 12 members of Charleston's Emanuel AME educational settings. Additional considerations for Church in a bible study. After sitting with them for and challenges with the use of telehealth approximately one hour, he opened fire on them, consultation will also be discussed. murdering nine of the 12. Tywanza Sanders, his great aunt Susie Jackson, Reverend Senator Clementa Sunday, October 22, 2017 Pinckney, Reverend Daniel Simmons, Sr., Reverend Sharonda Coleman Singleton, Reverend DePayne Rapid-Fire Talks: Focus on Criminal Justice Middleton Doctor, Myra Thompson, Ethel Lance, and Collaborations Cynthia Hurd were murdered. Tywanza's mother, Felicia Sanders, and her 10-year-old granddaughter No. 1 survived by feigning death. The murderer told Polly It’s My Trauma, Too: Debriefing Groups to Help Sheppard that he was allowing her to live so she Psychiatrists Process Traumatic Community Events could share what had happened. He hoped his and Address Compassion Fatigue in Baton Rouge, actions would incite a race war. The Charleston LA Dorchester Mental Health Center (CDMHC) began Presenter: Eva Mathews, M.D., M.P.H. serving the survivors and the families the night of Co-Authors: Deonna Dodd, M.D., Shanique Ampiah, massacre. The Charleston Police Department (CPD) M.D. deployed the CDMHC clinician embedded with the police department to the hotel where families had EDUCATIONAL OBJECTIVE: been gathered. The following day, CDMHC was At the conclusion of this session, the participant called in to meet with the FBI and the CPD to plan a should be able to: 1) Define compassion fatigue; 2) family assistance center. The center then established Consider debriefing groups as a tool to help mental a church assistance center to address the immediate health providers process community trauma; and 3) needs of the congregation. The center deployed Offer suggestions for mental health providers in clinicians to every wake and funeral and most prayer other communities should they experience vigils. The center assisted the church in a funeral traumatic community events. planning meeting with the nine families. The center opened its doors to the community in the evenings SUMMARY: following the shooting for folks who needed a place Part of Rapid-Fire Talks: Focus on Criminal Justice to talk about their sadness and their shock. The Collaborations center worked with the children of the church through its vacation bible school. Center staff were No. 2 present at Mother Emanuel worship services every Tragedy in the Sanctuary: The Charleston Sunday after the shooting until December 2015. The Community’s Response to the Emanuel AME center partnered with the National Crime Victims Massacre Center at MUSC to provide ongoing grief support Presenter: Deborah S. Blalock, M.Ed., L.P.C.S. groups and eventually establish an empowerment center on the grounds of the church with financial EDUCATIONAL OBJECTIVE: support from the Office of Victims of Crime. The At the conclusion of this session, the participant clinical support team provided guidance to the church and city of Charleston as they planned the Integrating Behavioral Health and Primary Care: first anniversary memorial events. The clinical team Practical Skills for the Consulting Psychiatrist also attended the women's ministry and seniors' Director: Anna Ratzliff, M.D., Ph.D. ministry meetings to reach out to more folks. The Faculty: John Kern, M.D. powerful lessons learned on this journey have been many. Race had to be addressed in a bold, yet EDUCATIONAL OBJECTIVE: sensitive way. The entire community felt pain; so At the conclusion of this session, the participant many layers of victims had to be served. Law should be able to: 1) Make the case for integrated enforcement, fire service, coroners, and media behavioral health services in primary care, including sought clinical assistance. Decisions had to be made the evidence for collaborative care; 2) Discuss about which clinicians should serve the church and principles of integrated behavioral health care; 3) which should not. The church suffered multiple Describe the roles for a primary care consulting losses, which had to be acknowledged and psychiatrist in an integrated care team; and 4) Apply addressed. Family dynamics, varied as the family a primary care-oriented approach to psychiatric members, had to be navigated by clinicians. consultation for common behavioral health Reaching the men in the church remains a challenge. presentations. Currently, the clinical team is attending the federal death penalty trial with families. Treatment and SUMMARY: support will be provided for at least the next three Psychiatrists are in a unique position to help shape years. mental health care delivery in the current rapidly evolving health care reform landscape using No. 3 integrated care approaches in which mental health is Dealing With Addictions From Policing to the delivered in primary care settings. In this model of Criminal Justice System care, a team of providers, including the patient's Presenter: Elie G. Aoun, M.D. primary care provider, a care manager and a psychiatric consultant, work together to provide EDUCATIONAL OBJECTIVE: evidence-based mental health care. This course At the conclusion of this session, the participant includes a combination of didactic presentations and should be able to: 1) Recognize the strengths and interactive exercises to provide a psychiatrist with weaknesses of law enforcement training in working the knowledge and skills necessary to leverage their with individuals with SUD; 2) Understand the state of expertise in the collaborative care model—the the services offered to incarcerated individuals with integrated care approach with the strongest SUD and their limitations; 3) Identify the role of evidence base. The first part of the course describes mental health professionals in assisting law the delivery of mental health care in primary care enforcement officials interacting with individuals settings with a focus on the evidence base, guiding with SUD; 4) Describe the interventions available for principles and practical skills needed to function as a SUD at each stage of arrest and incarceration and primary care consulting psychiatrist. The second part how these interventions actually affect outcomes; of the course is devoted to advanced collaborative and 5) Discuss recommendations for the treatment care skills. Topics include supporting accountable of SUD in the criminal justice system. care, leadership essentials for the integrated care psychiatrist and an introduction to implementation SUMMARY: strategies. Core faculty will enrich this training Part of Rapid-Fire Talks: Focus on Criminal Justice experience by sharing their own lessons learned Collaborations from working in integrated care settings. The APA is currently a Support and Alignment Network (SAN) Special Sessions that was awarded $2.9 million over four years to train 3,500 psychiatrists in the clinical and leadership Friday, October 20, 2017 skills needed to support primary care practices implementing integrated behavioral health programs. The APA's SAN will train psychiatrists in state of the art knowledge in treating diabetes, the collaborative care model in collaboration with hypertension and dyslipidemias; 3) Develop skills in the AIMS Center at the University of Washington. understanding the use of treatment algorithms for This training is supported as part of that project. prevalent chronic illnesses in the SMI population; 4) Increase comfort in using screening guidelines for Saturday, October 21, 2017 early identification of common diseases; and 5) Understand key concepts in prevention and Conversations on Diversity treatment related to obesity, tobacco use and Chair: Ranna Parekh, M.D. vaccinations. Presenters: Helena B. Hansen, M.D., Ph.D., Vabren Watts, Ph.D. SUMMARY: Patients with mental illness, including those with EDUCATIONAL OBJECTIVE: serious mental illness (SMI), experience At the conclusion of this session, the participant disproportionately high rates of tobacco use, should be able to: 1) Afford APA members the obesity, hypertension, hyperlipidemia and opportunity to share experiences, history and disturbances in glucose metabolism. This is often perspectives about diversity in organized psychiatry; partially the result of treatment with psychiatric 2) Discuss how health care and patient medications. This population suffers from demographics are impacted by diversity; and 3) suboptimal access to quality medical care, lower Share ideas that will help the APA better serve its rates of screening for common medical conditions MUR constituents, patients and communities. and suboptimal treatment of known medical disorders such as hypertension, hyperlipidemia and SUMMARY: nicotine dependence. Poor exercise habits, Conversations on Diversity and Health Equity With sedentary lifestyles and poor dietary choices also APA Members was created in 2015 to provide a contribute to excessive morbidity. As a result, setting where all APA members could share mortality in those with mental illness is significantly experiences, histories and perspectives about increased relative to the general population, and diversity. Additionally, the program serves to help there is evidence that this gap in mortality is growing the APA and the Division of Diversity and Health over the past decades. Because of their unique Equity (DDHE) customize goals and programming. background as physicians, psychiatrists have a Participant feedback is used to assist the APA/DDHE particularly important role in the clinical care, in better serving its MUR constituents, patients and advocacy and teaching related to improving the families. The event is evolving as a platform for medical care of their patients. As part of the broader members to increase awareness and cultural medical neighborhood of specialist and primary care competence and to facilitate their understanding of providers, psychiatrists may have a role in the diversity as a driver of health care and institutional principal care management and care coordination of excellence. some of their clients because of the chronicity and severity of their illnesses, similar to other medical Primary Care Skills for Psychiatrists specialists (nephrologists caring for patients on Chair: Jeffrey T. Rado dialysis, or oncologists caring for patients with Presenters: Lori Raney, M.D., Lydia Chwastiak, M.D., cancer). The APA recently (July, 2015) approved a M.P.H., Jaesu Han, M.D., Alyson Myers, Martha C. formal Position Statement calling on psychiatrists to Ward, Amy Newhouse embrace physical health management of chronic conditions in certain circumstances. Ensuring EDUCATIONAL OBJECTIVE: adequate access to training is an essential aspect of At the conclusion of this session, the participant this new call to action. There is a growing need to should be able to: 1) Review the causes of excess provide educational opportunities to psychiatrists mortality in the SMI population and discuss lifestyle regarding the evaluation and management of the modifications that are useful; 2) Improve current leading cardiovascular risk factors for their clients. This course provides an in-depth, clinically relevant centered medical home, the Patient Aligned Care and timely overview of all the leading cardiovascular Team. Although the VA does not rely on the fee for risk factors which contribute heavily to the primary service reimbursement methodology that has cause of death of most persons suffering with SMI, slowed the growth of integrated care throughout the and allows for the profession of psychiatry to begin rest of health care, implementation of the program to manage some of the leading determinants of has been slow and uneven across the system. mortality and morbidity in patient populations Successful implementation in most sites often frequently encountered in psychiatric settings. requires reassigning and retraining staff accustomed to working in traditional mental health clinics. With Symposia the rising workload following the recent wars in Iraq and Afghanistan, many facilities struggle to keep up Thursday, October 19, 2017 with demand for specialized mental health (MH) care, and leaders are often reluctant to reassign staff Improving Access and Treatment Engagement from those programs to primary care. At present, Through Integrated Care: Translating National most integrated care programs are staffed at about Policy Into Local Practice in the VA half or less of the recommended levels. Despite Chair: Andrew S. Pomerantz, M.D. these limitations, national evaluation to date has Presenters: Marsden Hamilton McGuire, M.D., Peter demonstrated the effectiveness of this initiative in Hauser, M.D., Paul Deci, M.D. improving the likelihood that veterans in need of Discussant: Lori Raney, M.D. mental health care will receive it. Veterans and the general public have demanded better access to VA EDUCATIONAL OBJECTIVE: health care, particularly to MH care. In 2016, a At the conclusion of this session, the participant bipartisan committee appointed by congress to should be able to: 1) Understand the complex review VA health care provided support for the challenges of developing and overseeing quality of VA health care and lauded its integrated implementation of national policy in a very large care efforts. The commission also stressed the need health care system; 2) Have familiarity with the to improve access. VA leadership identified components of integrated care that differentiate it integrated care as a key strategy to meet this need from traditional specialty mental health care; 3) as well as to meet public demands to improve Build on the lessons learned at the VA to develop suicide prevention by enhancing early intervention. local solutions to overcome common barriers when As a result, in mid-2016, the VA began a systematic implementing integrated care programs; and 4) effort to improve implementation. By the end of Understand many of the mental health concerns December 2016, same day access for individuals unique to the veteran population. identified with mental health conditions in VA primary care clinics increased by 10%. In addition to SUMMARY: improving access, program evaluation has In 2005, the American Psychiatric Association demonstrated significant improvements in recognized the contribution of integrated care to addressing the mental health needs of veterans improving access to mental health services by receiving primary care services in the VA by awarding its gold achievement award to the White increasing identification and engagement in River Junction (Vermont) Veteran Affairs (VA) evidence-based treatment. In this symposium, VA medical center's Primary Mental Health Care MH national, regional, and local leaders will review program. Soon afterward, the VA recognized the the challenges of operationalizing national policy value of this program, and in 2007, all VA medical into tangible clinical practice, as well as review the centers and larger community-based outpatient outcomes of implementation from national, clinics (CBOCs) were required to begin regional, and local perspectives. Factors necessary implementation of this program. In 2011, the VA for success and important lessons learned will be further supported integrated care by incorporating discussed, with particular emphasis on elements the program into its newly developed patient- applicable across systems. policy implications, and will discuss effective ways to Friday, October 20, 2017 influence and educate lawmakers and their staff. Local New Orleans City Council members and mental Mental Health in All Policies: How to Partner With health activists will provide personal perspectives for Lawmakers to Improve Mental Health Outcomes in building and maintaining positive collaborative Our Communities relationships with psychiatrists and other mental Chair: Ruth Shim, M.D., M.P.H. health professionals. Presenters: Marc Manseau, M.D., M.P.H., Joshua Berezin, M.D., M.S., Kevin M. Simon, M.D. Outlaws: The Queer Intersection of LGBTQ Rights, Mental Health, and the Law EDUCATIONAL OBJECTIVE: Chairs: Vivek Datta, M.D., M.P.H., Brian Holoyda, At the conclusion of this session, the participant M.D., M.B.A., M.P.H. should be able to: 1) Describe the "Health in All Presenters: Brian Holoyda, M.D., M.B.A., M.P.H., Policies" approach and apply it to a mental health Andrew N. Tuck, B.Sc., Vivek Datta, M.D., M.P.H., framework; 2) Work actively to improve mental Ariana Nesbit, M.D., M.B.E., Darlinda Minor, M.D., health policy at a local government level; 3) Marshall Forstein, M.D. Understand how to critically evaluate and screen bills for mental health policy implications; and 4) EDUCATIONAL OBJECTIVE: Interact with local governmental officials (including At the conclusion of this session, the participant legislators and staffers) to advance sound mental should be able to: 1) Briefly describe the history of health policy. psychiatry as it pertains to LGBTQ rights; 2) Understand what constitutes “conversion therapy,” SUMMARY: who practices it, why, and the backlash against it; 3) The social determinants of mental health (those Discuss the arguments for and against legislation factors stemming from where we grow, live, work, banning “conversion therapy” and the implications learn, and age that impact our overall health and for psychiatric practice; 4) Use the minority stress well-being) are responsible for many of the theory to describe how legislated discrimination disparities and inequities we see in mental health against trans people can lead to psychiatric outcomes in our society. These social determinants morbidity; and 5) Describe the role of the are shaped by public policies and social norms; psychiatrist in evaluating the LGBTQ individual therefore, they are modifiable through social and seeking political asylum. public policy interventions. Significant progress in addressing the social determinants of health has SUMMARY: been made by adopting a "Health in All Policies" The history of psychiatry and LGBTQ rights is approach, which incorporates health into decision complex, and the narrative is ongoing. The removal making across various sectors and policy arenas. This of homosexuality from the DSM has undoubtedly symposium expands the Health in All Policies advanced the rights of those who identify as lesbian, initiative to consider "Mental Health in All Policies" gay, or bisexual. Adoption rights, same-sex marriage, and equips mental health professionals with the and the repeal of Don’t Ask Don’t Tell would never tools to effectively engage and interact with local have occurred if homosexuality continued to be seen governments to shape public policies. Few mental as the developmental end-point of deep-seated health providers feel adequately prepared to psychopathology. Despite this progress, LGBTQ interact with legislators and other policy influencers individuals continue to face discrimination. Sexual in their local governments, despite the fact that orientation change efforts (SOCE), or so-called these relationships can prove most effective in “conversion therapy,” continues to be practiced directly addressing the social determinants of despite its potential to cause psychiatric harm, mental health. Presenters will discuss how to leading to legislation against it. Laws banning establish relationships with lawmakers, learn conversion therapy have been subject to appeals techniques for examining bills for mental health challenging their constitutionality based on claims they violate the first amendment. We will discuss the practices. The evidence is quite clear, however, that arguments for and against this legislation and the such patients are commonly seen in EDs, are at potential adverse consequences of such bans on elevated risk for suicide, are at elevated risk for psychiatric practice. Recently, there has also been a aggression and agitation, and are prone to extended wave of legislation focusing on prohibiting trans ED stays. More fundamentally, they pose very people from using the bathroom congruent with challenging clinical questions to emergency their gender identity. Using the minority stress psychiatrists. First, when is a patient "sober enough" theory, we will discuss the psychiatric consequences for a psychiatric evaluation? Many hospitals adhere of enshrining discrimination in legislation. Finally, we to "sober by the numbers" or "clinically sober" as will explore how the continuing criminalization of prerequisites to psychiatric evaluation. Definitions LGBTQ individuals by governments and remain ambiguous for both: is sober by the numbers pathologization by psychiatric associations in other a BAL under the driving limit or does it need to be countries may lead these individuals to seek asylum nondetectable? How do we assess somebody as in the United States and the role of the psychiatrist being "clinically sober" when a central question will in these cases. be the quality of their insight and judgment? How do we determine either for a patient using other Sobering Thoughts: Challenges and Controversies in psychoactive substances such as benzodiazepines or Emergency Assessment of Intoxicated Patients With cannabis, medically prescribed or otherwise? Next Suicide or Aggression Risk arises the clinical question: how effective is a sober Chairs: John S. Rozel, M.D., M.S.L., Margaret E. evaluation of a patient now recanting suicidality with Balfour, M.D., Ph.D. little insight or recollection of what drove their Presenters: Chinenye Onyemaechi, M.D., Camille recent suicidal statements in comparison to what Paglia, M.D., J.D., David Pepper, M.D., Tara Pundiak they may have revealed during a careful interview Toohey, M.D., L. Lee Tynes, M.D., Ph.D., David while they were still intoxicated? Does it make sense Yankura, M.D. to admit a patient who made significant suicidal or Discussant: Leslie Zun, M.D. aggressive statements during a rare or isolated alcohol binge, especially if they may not even recall EDUCATIONAL OBJECTIVE: the concerning behaviors? Finally, should we At the conclusion of this session, the participant approach the persistently intoxicated patient should be able to: 1) Apply research on the risks of differently from the sporadically intoxicated patient? subsequent dangerousness in patients who make This symposium will explore the evidence and threats to harm themselves or others while clinical best practices for evaluating and managing intoxicated; 2) Understand the clinical and people presenting for evaluation after threats made operational questions around timing the evaluation while intoxicated. Several case examples will be of patients who present intoxicated to psychiatric used, and audience members will be invited to emergency settings; 3) Evaluate legal and ethical participate in role plays. Guidance will be provided challenges of evaluation while sober or while on best practices both for individual psychiatrists as intoxicated; and 4) Understand the relative merits well as for structuring policies and practices for and limitations of clinical and laboratory evaluation emergency departments. of intoxication and sobriety. Saturday, October 21, 2017 SUMMARY: Emergency department evaluation of patients who Bringing Evidence-Based Practices to the People: present intoxicated offers significant clinical, ethical, The Philadelphia Story and logistical challenges. This is particularly the case Chair: Lawrence A. Real, M.D. for patients who made suicidal or aggressive Presenters: Ronnie M. Rubin, Ph.D., Torrey A. Creed, statements or acts while intoxicated. Despite the Ph.D., Daisy R. Lugo, Psy.D., Allison M. Odle, M.S.Ed., frequency of such presentations, there is little in the M.S., L.P.C., Rinad S. Beidas, Ph.D. literature to provide clear guidance on best Discussant: Arthur C. Evans, Ph.D. have trained over 600 therapists in over 60 EDUCATIONAL OBJECTIVE: programs, while embedding 12 EBPs in our network At the conclusion of this session, the participant of care, within multiple treatment settings and levels should be able to: 1) Explain how the infusion of of care. In the second presentation, the evolution of evidence-based practices (EBPs) into a public the Beck Community Initiative—in place for nearly behavioral health system is consistent with that 10 years—will be discussed in depth, with special system’s transformation to a recovery and resilience emphasis on its transdiagnostic utility and on crucial orientation; 2) Discuss why successful "lessons learned" about organizational engagement, implementation of EBPs in a public behavioral health scale, and sustainability. We will then hear from system necessitates a focus on organizations and representatives of one of our provider agencies, programs and not just the training of individual whose adaptation of cognitive therapy has spread therapists; 3) List three commonly occurring barriers from one treatment program into a deeply to sustaining EBPs at the provider level and embraced, guiding principle for the entire agency. In strategies for overcoming them; and 4) Apply lessons the final presentation, the Philadelphia Story will be learned in Philadelphia to facilitate the placed in the broader perspective of EBP efforts implementation of EBPs in their agency or system of elsewhere in the United States, which have utilized care. alternative approaches such as legislative mandates, and within the growing field of implementation SUMMARY: science research. The architect of the EBP initiative, Over the past several decades, researchers have former department commissioner Dr. Arthur C. identified a growing number of evidence-based and Evans, will serve as discussant, and he will also be innovative practices that are effective in supporting featured, along with Dr. Aaron T. Beck, the "father of people with behavioral health challenges. Despite cognitive therapy," in an introductory video rising interest from all stakeholders in providing such discussing this unique blending of scientific findings evidence-based practices (EBPs) to improve the and recovery principles. We are hopeful that this quality of services and achieve meaningful outcomes symposium will stimulate the development of a for service recipients, research has also shown that learning community of like-minded partners and only rarely are these empirically supported systems. treatments available in community behavioral health settings. Since 2007, Philadelphia's Department of Climate Change: The Ultimate Social Determinant Behavioral Health has invested significantly in the of Health and Mental Health infusion of EBPs as an essential component of its Chair: David A. Pollack, M.D. system transformation, i.e., in using EBPs as a tool to Presenters: Janet L. Lewis, M.D., Carissa Cabán- support recovery and resilience outcomes, rooted in Alemán, M.D., Joshua C. Morganstein, M.D., Lise Van the vision that every person should have access to Susteren, M.D., Elizabeth Haase, M.D., Alex the treatments that are most efficient and effective. Schrobenhauser-Clonan, M.D., M.Sc. This symposium will explore how Philadelphia, via Discussant: H. Steven Moffic, M.D. unique partnerships with treatment developers, researchers, and providers, has approached the EDUCATIONAL OBJECTIVE: challenge of identifying, implementing, and At the conclusion of this session, the participant sustaining EBPs throughout its system of care. We should be able to: 1) Recognize the reality of climate will begin by describing the creation of the Evidence- change and its impact on health and mental health; Based Practice and Innovation Center to advance 2) Recognize specific psychiatric conditions that system-wide strategies and infrastructure, including emerge from and/or are affected by climate change increasing knowledge and acceptance of EBPs; and the treatments that are being studied and integrating them within system policy, fiscal, and recommended; 3) Recognize psychological factors, oversight functions; and looking at strategies to such as denial and hopelessness, that contribute to incentivize EBP delivery. We will trace the the refusal to acknowledge this environmental crisis, development of several key initiatives that, to date, as well as the failure to act to reverse or mitigate the local and global risks of climate change; and 4) inaction and join the global efforts to sustain Recognize the ethical and public health duties for meaningful life on this planet. psychiatrists and other mental health professionals to speak out about these threats and to advocate for Integrated Pain Management: An Approach to rational policies to address the threats to health and Alleviate Chronic Pain in the Era of the Opioid life posed by climate change. Epidemic Chair: Aruna Gottumukkala, M.B.B.S. SUMMARY: Presenters: Paul Sloan, Ph.D., Utpal Ghosh, Sybill Scientific evidence has unequivocally established the Kyle, M.S.N., R.N. reality of climate change and global warming. The Discussant: Linda L. M. Worley, M.D. processes of increasing global temperatures, rising ocean levels, and extreme weather events are EDUCATIONAL OBJECTIVE: directly attributable to continued extraction and At the conclusion of this session, the participant consumption of carbon-based fuels and the failure should be able to: 1) Understand the bidirectional to rapidly develop and implement alternative fuels, relationship between psychiatric disorders and sustainable alternative energy sources, or chronic pain; 2) Define the role of the meaningful conservation practices. These negative interdisciplinary team in assessment and processes are already affecting the environment, management of pain; 3) Outline the principles of the plant and animal ecosystems, availability of natural stepped care model and the role of behavioral resources, and human behavior at individual, interventions in pain management; and 4) Learn the community, national, and international levels. These importance of opioid risk assessment and review impacts will only escalate and create catastrophic harm reduction strategies. conditions for most inhabitants of the Earth, especially if no meaningful and timely efforts are SUMMARY: effectively implemented to mitigate the processes Pain poses a major public health challenge, affecting and trends that have already been observed. Climate 40% of the general population (100 million change is already impacting human health and well- Americans). However, more than 50% of enrolled being, including the emergence of psychiatric veterans and almost 60% of veterans returning from syndromes that are directly tied to these the recent war suffer from pain-related environmental changes as well as the complications symptomatology. Chronic pain poses an economic that are and will be experienced by persons with burden with significant impact on work and quality various preexisting psychiatric disorders. of life, resulting in severe functional disability (over Psychiatrists and other health and mental health 10%). Despite increasing awareness of the professionals must become aware of and adept at biopsychosocial aspects of pain and the bidirectional recognizing and treating these clinical issues. In relationship between chronic pain and comorbid addition, there is much evidence that key psychiatric disorders, accurate attribution of psychological defenses and thinking errors—in symptoms and diagnosis and choosing an effective particular denial and hopelessness—operate at treatment have become a clinical challenge. Chronic individual and societal levels in ways that prevent, pain has predominantly been treated in specialty frustrate, and even reverse climate change pain clinics for the past several decades, often with mitigation initiatives. Citing communications science, opioids, resulting in an epidemic of deaths from disaster psychiatry, and other resources, presenters opioid overdoses. In response to the epidemic, the will review and recommend appropriate actions for Centers for Disease Control and Prevention (CDC) psychiatrists and other mental health professionals has recently published "Guidelines for Prescribing to utilize. We will review ethical and public health Opioids for Chronic Pain-United States, 2016," obligations that should motivate psychiatric intended for primary care physicians. The U.S. providers to speak out as individual health Surgeon General released the first ever report on professionals and as members of health professional alcohol, drugs, and health, calling for a cultural shift organizations to overcome societal denial and to end the stigma and emphasizing the need for a focus on effective treatment and recovery. Effective treat LGBTQ racial and ethnic minorities; and 5) management of chronic pain needs a combination of Identify the interaction between sexuality and strategies within primary care settings, including culture and its positive and negative impacts. early interventions to minimize the progression to chronic pain, suffering, and disability and to improve SUMMARY: quality of life and functional recovery. In this In this symposium, presented with affiliation from symposium, we will discuss outcomes of the clinical the Association of LGBTQ Psychiatrists (AGLP), the interventions that our integrated pain evaluation unique issues faced by lesbian, gay, bisexual, and clinic adopted at Michael E. DeBakey VA medical transgender people of color (LGBTQ-POC) will be center, which is one of the largest medical centers in explored from multiple angles. Current events in the the United States. We first review the epidemiology world will be used as a lens to examine these of pain, biopsychosocial factors that contribute to challenges and the resulting psychiatric impact to pain, and the neurobiological basis for the these communities. Afterward, treatment strategies bidirectional relationship between pain and will be explored in order to best serve this psychiatric disorders. We will discuss the unique community at an individual and a system-wide level. roles and perspectives of different team members in The first presentation deals with substance use in our interdisciplinary team, as they provide pain LGBTQ-POC. These communities have been assessment and treatment. We will review the disproportionately affected by the drug epidemic in elements of the stepped-care model for pain the United States. This has resulted in many negative management (SCM-PM) and the evidence that health outcomes, both in terms of physical health supports nonpharmacological behavioral and certainly in terms of mental health. This is from interventions for pain management. We will then a combination of factors. First, substances discuss the importance of using tools for opioid risk themselves lead to negative psychiatric outcomes. assessment and the role of office-based Second, substance use creates severe social and buprenorphine, case management, and opioid financial stressors including homelessness and lack education and naloxone distribution (OEND) of any social support, which greatly exacerbates all programs as a harm reduction strategy. We will end psychiatric conditions. Finally, resulting targeting of by discussing the clinical and legal interface between minorities and mass incarceration in these pain management and substance use disorders and communities have affected people's ability to get how patients can be triaged so that they receive care help and have damaged trust with the system. The in the clinical setting most suitable for their needs. next topic is about double discrimination. It is widely known that discrimination negatively impacts both LGBTQ People of Color (POC): How Current Events the physical and mental health of minority groups. Reveal Unique Challenges and Treatment Members of multiple-minority groups, such as Opportunities LGBTQ-POC, are disproportionately at risk for Chair: Amir K. Ahuja, M.D. negative health outcomes due to chronic stress from Presenters: Jose Vito, M.D., Vivek Datta, M.D., stigmatization, discrimination, and fear of rejection. M.P.H., Kali D. Cyrus, M.D., M.P.H., Matthew Using the minority stress model, which analyzes the Dominguez, M.D., M.P.H. complex relationship between external Discussant: Kenn Ashley (discrimination/prejudice) and internal (self- doubt/rumination) stressors, we will attempt to EDUCATIONAL OBJECTIVE: understand the lived experiences of LGBTQ-POC in At the conclusion of this session, the participant this tense political context and will examine our role should be able to: 1) Identify the unique issues that as mental health providers in exploring how these LGBTQ ethnic and racial minorities face; 2) Describe threats shape the experience of our multiple- how being a double minority can increase stress and minority patients. The next topic involves the lead to negative health outcomes; 3) Identify the intersection between being LGBTQ and cultural issues surrounding substance use in racial and ethnic values of racial and ethnic minority groups using the LGBTQ communities; 4) Employ strategies to better example of the Orlando shooting of 2016, which shocked the nation as the deadliest mass shooting in Opioid abuse during pregnancy has been growing in U.S. history. It is also noticeable for being an act of frequency and severity. Recent data demonstrate terror perpetrated by LGBTQ-POC against other large increases in newborns born dependent on LGBTQ-POC. In this presentation, we will explore the drugs (neonatal abstinence syndrome), with hospital psychological impact of conflicted sexuality as it costs associated with treating them estimated at occurs in LGBTQ-POC, sometimes with tragic $1.5 billion annually. These figures do not include consequences. Further, we will discuss the costs associated with treating mothers with drug psychological effects of internalized homophobia addictions or long-term costs in meeting the and latent or repressed homosexuality in LGBTQ- developmental, health, and educational needs of POC. Finally, a treatment approach combining infants exposed to substances in utero. They do psychodynamic and cognitive-behavioral approaches include burgeoning costs of foster care, child will be proposed, with the goal of guiding patients welfare, and judicial involvement. While as many as toward an integrated sense of self and improving the 20% of women experience new-onset and recurrent capacity for the formation of secure attachments. major mood, anxiety, and even psychotic disorders The application of the principles of trauma-informed prenatally and in the postpartum period, serious care to working with LGBTQ-POC will also be mental illness is underrecognized and often not considered. addressed. Perinatal mental health concerns are associated with obstetrical and neonatal Maternal Substance Abuse and Neonatal complications and can contribute to premature Abstinence Syndrome: Multidisciplinary birth, biological risk, increased cesarean delivery, Collaboration to Promote Engagement, Recovery, and postpartum depression. These high-risk and Infant Development situations can subsequently contribute to abuse and Chair: Howard J. Osofsky, M.D., Ph.D. neglect and resultant child behavioral and emotional Presenters: Erich Conrad, M.D., Joshua D. Sparrow, problems. Medical and mental health risk factors M.D., Robert Maupin, Joy D. Osofsky, Ph.D. also adversely influence parent-infant attachment and infant development. A collaborative program of EDUCATIONAL OBJECTIVE: the departments of psychiatry, obstetrics and At the conclusion of this session, the participant gynecology, and pediatrics at Louisiana State should be able to: 1) Understand current University Health Sciences Center, with focus on information about mental and behavioral health mental health and substance abuse, is addressing interventions for maternal substance abuse during the need to improve quality of care to improve pregnancy, neonatal abstinence syndrome, and outcomes for high-risk mothers and infants. With related problems following delivery; 2) Demonstrate patient input, senior clinicians from the three knowledge of evidence-informed psychiatric and departments are developing more comprehensive mental health practices for pregnant women abusing and integrated services, with continuity of care substances and barriers to treatment; 3) Understand provided at delivery, during neonatal intensive care, the complex factors that affect prenatal substance and follow-up infant care. Maternal and infant abuse leading to increased developmental risk and health specialists—masters-level social workers with infant mental health; 4) Learn about methods to expertise in trauma, mental illness, and substance support the developing parent-child relationship abuse—collaborate with physicians and staff, meet prior to and following birth and the benefit of with the mothers when they come for trauma-informed prenatal and neonatal mental appointments, and follow up between appointments health services and interventions; and 5) Learn to provide a supportive relationship during about a multidisciplinary program that increases the pregnancy and after the baby is born. Senior quality and continuity of mental health services and clinicians provide education for physicians, residents training of nonmental health professionals to from the three specialties, and hospital staff on improve maternal and infant well-being. patient and cultural sensitivity, motivational interviewing, and evidence-informed parent-infant SUMMARY: interventions. Early intervention to prevent medical and behavioral health problems, including those describe the problem but, using the results of the related to substance abuse, has been shown to be GAP publication, to provide specific examples of how cost effective and to benefit society at large. In order participants can take action in their own practices, to improve care and outcomes, there is a need for programs, and local systems, within available increased coordination and collaboration across resources. The foundation of the GAP report was departments, institutions, and systems; however, soliciting letters from Dear Abby's column describing there are few integrated and comprehensive stories of individuals and families with behavioral programs. Evidence indicates that this innovative health conditions who had been incarcerated. The program is of much benefit to mothers and infants committee received over 3,000 letters. These letters and that it will reduce short- and long-term costs by are not only used to engage the listener in the increasing access and utilization of mental health experiences of "real people," they were used by the support for maternal and infant well-being. committee as "case examples" for illustrating innovative practice and program approaches for People With Mental Illnesses in the Criminal Justice improving services to prevent or reduce System: Answering a Cry for Help incarceration. In line with the report, this symposium Chair: Kenneth Minkoff, M.D. will organize the discussion according to the Presenters: Stephanie Le Melle, M.D., M.S., sequential intercept model, developed by Dr. Mark Jacqueline M. Feldman, M.D. Munetz, one of the committee members. At each Discussant: Fred C. Osher, M.D. intercept point, there are illustrations for how to respond to the scenarios in the letters, with EDUCATIONAL OBJECTIVE: recommendations for action steps that lead to At the conclusion of this session, the participant changes in clinical practice, program policy, and local should be able to: 1) Understand the experiences of system collaboration and that can be undertaken by individuals and families with mental illness and psychiatrists, program leaders, and other substance use disorders in the criminal justice practitioners working at any level. After introducing system; 2) Be familiar with the use of the sequential the letters and describing the sequential intercept intercept model to design interventions to prevent model, each presenter in the symposium will focus and reduce incarceration; 3) Learn and practice on a particular intercept, using specific examples. specific strategies at each intercept for how to The intercepts include provision of proactive and improve outcomes as an individual practitioner; 4) welcoming crisis response to prevent arrest, Learn specific strategies for how to make a partnering with law enforcement and court difference in your own organization, program, or personnel after arrest, collaborating with judges system; and 5) Understand how to create a system around sentencing and therapeutic justice, impact through participation in the national partnership between community systems and jail- Stepping Up initiative. based services, and partnership with community corrections to provide integrated interventions to SUMMARY: address co-occurring disorders and criminogenic risk. Justice involvement of people with mental illness, Each of these areas will provide an opportunity to often with co-occurring substance use disorders, has involve participants in thinking and talking about reached critical levels. Hundreds of thousands of what they might be able to change in their own people with serious mental illness are incarcerated, settings. Finally, our discussant will engage and many more are under community correctional participants in thinking about opportunities to supervision. An APA publication from the Group for influence systems change on the state and national the Advancement of Psychiatry (GAP) Committee on level through describing the Stepping Up initiative. Psychiatry and the Community serves as the Our discussant will raise further questions and set foundation for this symposium. The symposium the stage for active audience engagement on this begins with a brief context of the problem of justice clinically, politically, and ethically challenging topic. involvement for individuals with mental illness. The focus of the symposium, however, is not just to Telepsychiatry in High-Risk Settings Chair: Rachel Zinns, M.D. emergency room visits, eight percent fewer Presenters: Stephen Ferrando, M.D., Anthony Ng incidents of suicide or violence, and seven percent Discussant: John Santopietro, M.D. fewer medical/surgical hospitalizations. Another speaker will present outcomes from a recently EDUCATIONAL OBJECTIVE: opened telepsychiatry inpatient unit (the first in New At the conclusion of this session, the participant York State) and strategies for managing risk on should be able to: 1) Discuss the evidence base for inpatient units and psychiatric emergency rooms. A using telepsychiatry to treat high-risk populations; 2) third speaker will discuss telepsychiatry consultation Assess telepsychiatry implementation models with to a large system of medical emergency rooms, respect to safety measures; and 3) Identify strategies where telepsychiatry services have reduced length for managing clinical risk in telepsychiatry. of ER stay by 50% and restrained transports by 70- 90%. A fourth speaker will discuss strategies for SUMMARY: employing and training telepsychiatrists to work in Telepsychiatry has been used with increasing high-risk settings, ranging from inpatient units and frequency to mitigate physician shortage and to emergency rooms to outpatient mental health clinics improve access to psychiatric treatment. Indeed, the and primary care offices. need for telepsychiatry services has been so great that clinical practice has outpaced research on the Workshops topic. Moreover, outcome studies on telepsychiatry tend to look at quality measures such as patient Thursday, October 19, 2017 satisfaction, wait times, and no-show rates. Few studies measure clinical outcomes, and even fewer Big Goals, Small Steps: The Psychiatrist’s Journey to do so in high-risk populations. Because of this, Advocate psychiatrists are often hesitant to treat psychotic or Chair: Sarah Y. Vinson, M.D. suicidal patients using telepsychiatry. The purpose of Presenters: Ruth Shim, M.D., M.P.H., Kenneth our symposium is to present the audience with both Thompson, M.D., Wesley E. Sowers, M.D., Rupinder evidence of the effectiveness of telepsychiatry for Legha high-risk populations and a framework for assessing telepsychiatry implementation models across varied EDUCATIONAL OBJECTIVE: clinical settings with respect to safety measures. At the conclusion of this session, the participant Both systems-based and interpersonal strategies for should be able to: 1) Identify various forms of minimizing and managing clinical risk through physician advocacy; 2) Discuss the psychiatric telepsychiatry will be presented. One speaker will physician’s role as advocate; 3) Identify potential discuss outpatient telepsychiatry, including a roadblocks to advocacy efforts; and 4) Collaborate retrospective study in which all the patients in a with colleagues to develop personalized, actionable state hospital-operated outpatient clinic were steps for advocacy. treated solely by telepsychiatry by one psychiatrist for a year. Compared to the previous year, when the SUMMARY: clinic received traditional in-person treatment by As physicians profoundly aware of the several "covering" psychiatrists, psychiatric biopsychosocial aspects of mental health and illness, hospitalization rates decreased from 23% to 18% psychiatrists have a unique lens for advocacy and incidence of suicide and violence decreased afforded by their expertise and training. Additionally, from 12% to 5%. Furthermore, clinical outcomes they have a natural platform for advocacy afforded from the telepsychiatry clinic were compared to by their title. For many, particularly in community outcomes from other clinics within the same state- psychiatry, professional identity shapes their role as hospital system. Compared to the averages from all citizens in the larger society. With a new federal the clinics in the system, the patients in the administration that has expressed great interest in telepsychiatry clinic had six percent fewer psychiatric the reform of the health care system as well as hospitalizations, seven percent fewer psychiatric safety net and entitlement programs, many resources upon which our patients depend are Presenter: Chuck Ingoglia subject to change in ways that could have significant implications for their health and well-being. While EDUCATIONAL OBJECTIVE: the uncertainty of practicing psychiatry in such an At the conclusion of this session, the participant environment can be challenging, it may also serve as should be able to: 1) Understand the requirements an inspiration for physician advocacy efforts. to become a certified community behavioral health Additionally, the threat of clinician burnout from center; 2) Understand the payment methodology for working with broken systems could, perhaps, be certified behavioral mental health centers; and 3) mitigated by a psychiatric workforce that uses its Understand how certified community behavioral voice in efforts to shape those same systems. The health centers will broaden and enhance the role of undertaking of advocacy, however, can be daunting. psychiatrists. In times of great polarization, the risks of being outspoken, particularly against those in power, may SUMMARY: be magnified. Some issues are of such complexity Certified community behavioral health centers that it can be difficult to have any idea where or how (CCBHCs) were created through Section 223 of the to start addressing them. And then there is the Protecting Access to Medicare Act (PAMA), which scarcity of time: between clinical, administrative, established a demonstration program based on the and personal demands, practically, where does Excellence in Mental Health Act. The Excellence in advocacy fit? In this workshop, four psychiatric Mental Health Act demonstration program—also physicians at various stages in their careers will known as the Excellence Act or the Section 223 discuss their journeys to advocacy. They will share demonstration program—is a two-year, eight-state how they identified their areas of activism; initiative to expand Americans' access to mental challenges they have faced; how their efforts have health and addiction care in community-based been shaped by the different social, political, and settings. In December 2016, the Substance Abuse academic environments in which they have and Mental Health Services Administration operated; and their lessons learned. The panelists announced the selection of the eight participating include Dr. Ken Thompson, medical director of the states: Minnesota, Missouri, New York, New Jersey, Pennsylvania Psychiatric Leadership Council and a Nevada, Oklahoma, Oregon, and Pennsylvania. The physician advocate fellow of the Institute of Excellence Act established a federal definition and Medicine as a profession at Columbia University; Dr. criteria for CCBHCs. These include 1) integrating both Ruth Shim, Luke and Grace Kim Professor in Cultural substance abuse and mental health services and Psychiatry, associate professor, department of behavioral health services with primary care; 2) psychiatry and behavioral sciences, University of becoming more data-driven—they are required to California, Davis; Dr. Rupinder Legha, child and collect and report data on 27 different performance adolescent psychiatry fellow at the University of indicators, some of which are costs, some utilization California, Los Angeles, and former fellow in global measures, some process measures, and some mental health at Partners in Health; and Dr. Wes outcome measures; some are behavioral health and Sowers, clinical professor of psychiatry at the some related chronic medical illness; 3) requirement University of Pittsburgh Medical Center and director to have a continuous quality improvement plan and of the Center for Public Service Psychiatry at process; 4) requirement to have 24-7 crisis response Western Psychiatric Institute and Clinic. The capability, including emergency crisis intervention, panelists' comments will prime the audience for an 24-hour mobile crisis teams, and crisis stabilization interactive workshop in which participants will share services; 4) requirement to make evening and and explore their own ideas about and methods for weekend hours available; 5) requirement to have a advocacy and activism. medical director; 6) requirement to actually directly provide (or contract with partner organizations to Certified Community Behavioral Health Centers provide) both substance abuse services and mental (CCBHC): The New CMHC on Steroids! health services; 7) requirement to provide Chair: Joseph Parks, M.D. medication-assisted treatment for addictions; 8) requirement that their patients get a general health With recent changes to health care delivery, the risk assessment and get monitored for metabolic opportunity to use patient registries to improve syndrome; and 9) requirement to have a formal quality of care and patient outcomes has never been system to assess the current competence of any staff greater. Registries seek to achieve several important providing treatment services. Overall, these goals, including supporting quality reporting by requirements provide a substantially higher level of physicians and other health care providers; performance than most CMHCs currently. CCBHCs improving the quality of care for patients; and receive an enhanced Medicaid reimbursement rate helping provide research data needed to develop based on their anticipated costs of care (prospective new quality measures as well as to improve payment). There is the option of doing a diagnostics and therapeutics. For psychiatrists, performance bonus payment. CMS has defined 11 specifically, a patient registry represents a simplified performance measures that must be met for any solution for meeting quality-reporting standards quality bonus payment to occur—the state can add while avoiding payment penalties for failure to additional quality bonus requirements, and states report on use of quality measures. It also will have wide discretion in how big a quality bonus facilitate psychiatrists meeting Maintenance of payment to make. Ultimately, the demonstration Certification (MOC) Part IV reporting requirements. program is expected to infuse more than $1.1 billion Given these benefits and the need to adapt to the into community-based services, making it the largest rapidly shifting landscape of care delivery into one investment in mental health and addiction care in based on quality reporting, the American Psychiatric generations. The prospective payment system will Association (APA) has developed a national mental remove the current financial disincentives that health registry (PsychPRO) that is a Centers for behavioral health organizations have to increase Medicare and Medicaid Services (CMS) Qualified psychiatric staffing. The requirement to have a Clinical Data Registry (QCDR). PsychPRO will aid medical director and the additional service participating psychiatrists, and other behavioral requirements will significantly broaden and enhance health providers, in meeting MIPS reporting the role of psychiatry. requirements. PsychPRO has improved upon earlier registries developed by other medical specialties by Developing a National Mental Health Registry incorporating clinician and patient Chairs: Saul Levin, M.D., M.P.A., Grayson Norquist, portals/dashboards. These portals are inter-operable M.D., M.S.P.H. and allow for the electronic (e-)assignment of Presenters: Diana E. Clarke, Ph.D., M.Sc., Debbie patient reported outcome measures (PROMs) such Gibson, M.Sc., Grayson Norquist, M.D., M.S.P.H., as the DSM-5 Review of Mental Systems, PHQ-9, Alvaro Camacho, M.D., M.P.H. AUDIT-C, neurocognitive battery, and the WHO-DAS Discussant: Anita Everett, M.D. 2.0 by the psychiatrist or his/her authorized administrative staff, the e-completion of the PROMs EDUCATIONAL OBJECTIVE: by the patient or their proxies, and the use of the e- At the conclusion of this session, the participant scored and e-transmitted results by the clinician in should be able to: 1) To help attendees understand his/her clinical evaluation of the patient. The the importance of the APA National Mental Health inclusion of these portals and the PROMs is a basic Registry; 2) To help attendees understand the but necessary step toward engaging patients in their importance of the inclusion of the clinician and evaluation and car e. Additionally, these PROMs can patient portals/dashboards as part of the APA aid the psychiatrist in meeting quality reporting Registry; 3) To help attendees understand the key requirements and avoiding payment penalties by features and functionalities of the clinician and augmenting data derived from the psychiatrist's patient portals/dashboards; and 4) To help electronic medical records (EMR). This workshop will attendees understand how the clinician and patient show how PsychPRO improved upon earlier portals can inform improvements in clinical care. registries developed by other specialties, discuss its security features, explain its benefits to clinicians SUMMARY: and their patients, demonstrate its features and functionalities, and lastly discuss how it can inform a system-wide approach to the integration of SUD overall improvements in clinical care. By the end of into MH and PH services; 2) Identify the six evidence- the workshop, attendees will be able to understand based principles of successful integrated treatment the benefits of the APA Registry and determine if and their associated interventions and practices; 3) they would like to participate in this important Use continuous quality improvement to implement initiative. integrated practices and services in any setting; 4) Be familiar with real-world implementation of SUD Evaluating Psychiatric Smartphone Apps: Applying integration in a regional provider system in the APA App Evaluation Model Louisiana; and 5) Identify specific next steps for Chairs: John Torous, M.D., Steven Chan, M.D., M.B.A. improving integration of SUD services in one’s own Presenters: Jung W. Kim, M.D., Shih Yee-Marie Tan setting or organization. Gipson, M.D. SUMMARY: EDUCATIONAL OBJECTIVE: It is well recognized that people seeking physical At the conclusion of this session, the participant health (PH) and behavioral health (BH) services have should be able to: 1) Know the four factors in the complex needs, including co-occurring mental health APA app evaluation model; 2) List at least three risk (MH), trauma, substance use (SUD), PH, cognitive, and three benefits of app use; and 3) Apply the APA and other human service challenges, and that app evaluation model to apps on the commercial providing integrated services to meet those needs is app store. a priority for successful achievement of the triple aim. In recent years, the focus of integration efforts SUMMARY: has increasingly been on PH-BH integration, leading Despite tremendous interest, there remain many to the impression that the "BH" (MH and SUD) important barriers and concerns toward using integration has been accomplished. This is, however, mobile technology like smartphone apps and fitness far from the case, and the recent opioid epidemic tracker data in clinical care. In this workshop, has made the need for attention to this issue even participants will learn to evaluate smartphone apps more pressing. This workshop addresses this issue using the APA smartphone app evaluation model head on, so that participants can leave with concrete through hands-on, interactive real-life cases/apps. ideas and next steps about how to improve Participants will be active learners in directly integration of SUD services into MH and PH services applying the APA smartphone app evaluation to apps in their own settings. The workshop begins with a they may already be using, or are interested in, and review of the need to prioritize people with co- learn how to make an informed choice whether that occurring conditions in all settings and specific app is appropriate for use with patients or not. Of principles and EBP interventions for integrating SUD note, no experience with technology or apps is into MH and/or PH in any setting for any population. necessary, and those not interested in using apps Specific practices to be addressed include welcoming will still learn how to discuss, approach, and frame and engagement, screening and identification, app use when patients may ask about such. integrated teamwork, assessment and service planning, stage-matched treatment, medication- Integrating Substance Use Disorder Services Into assisted treatment (buprenorphine, naltrexone), Complex Physical Health and Mental Health individual and group skill building, and peer recovery Systems support. Examples will be provided about areas of Chair: Kenneth Minkoff, M.D. challenge and progress in multiple state and local Presenters: Christie Cline, M.D., M.B.A., Aniedi systems across the U.S. The next presentation will Udofa, M.D. focus on how to engage an entire organization in making progress in integrating SUD services, so EDUCATIONAL OBJECTIVE: integration belongs to all staff and all programs. This At the conclusion of this session, the participant begins with a framework of customer-oriented should be able to: 1) Understand the importance of continuous quality improvement (CQI), recognizing that individuals using substances, particularly those socioeconomic status or personality to who are not immediately wanting to change, are at recommending a different treatment depending on a high risk of high cost and poor outcome and are patient’s ethnicity, gender, or disability status. A therefore a priority to welcome and engage in ANY recent study found that a black, working-class man setting with ANY team. This presentation will would have to call 16 times as many therapists illustrate the basic steps, tools, and strategies for before finding care. This can erode patient trust, inspiring and empowering all levels of an undermine therapeutic alliances, discourage patients organization to make measurable progress in from seeking care, and potentially worsen outcomes. implementing the integrated practices described. Providers also experience these biases and The final presentation will illustrate successful microaggressions, which undermine their ability to progress in integration of MH and SUD in a regional provide excellent care and may contribute to system in Louisiana. Capital Area Human Services burnout and worsen provider well-being. Indeed, (CAHS), a community-based behavioral health many academic institutions struggle to foster treatment organization, is a leader in the Baton diversity at the highest levels of their organizations. Rouge region, implementing innovative strategies An understanding of these factors is essential to for integrating MH, SUD, and PH services agency- increasing access to care, providing quality care, and wide. CAHS's successes and best practices will be fostering well-being among providers and patients. shared with participants, including universal MH and The workshop will involve participants engaging with SUD screening of clients accessing outpatient and microaggressions that occur on a daily basis in our residential treatment services and effective offices, clinics and hallways. A panel of facilitators identification and engagement of individuals with will lead a group discussion regarding identified MH and SUD problems through colocation of types and categories of microaggressions, common substance-trained MH professionals in a local FQHC, reactions and how they might affect our own parish prison, and prenatal clinic. interactions. Participants will be provided with resources to examine their own implicit biases and Microaggressions, Macroeffects: The Front Lines of we will conclude with strategies; both individual and the Fight Against Stigma systemic, to combat microaggressions and implicit Chair: Madeline B. Teisberg, D.O., M.S. biases in our daily practice. Questions and discussion Presenters: Megan Elizabeth Baker, M.D., Kimberly will be encouraged. Gordon, M.D., Patcho N. Santiago, M.D. Primary Care Clinician Retention as an Opportunity EDUCATIONAL OBJECTIVE: for Consulting Psychiatrists: Safety Net Clinics, At the conclusion of this session, the participant Experiences of New Hires, and Collaborative Care should be able to: 1) Understand microaggressions, Chair: John H. Wells II, M.D. implicit bias, and examples of how they affect Presenters: Stephanie Tokarz, M.P.H., Jason patient care; 2) Identify the ways in which Poyadou, Stephanie Losq microaggressions and implicit bias affect both patients and clinicians; and 3) Engage colleagues and EDUCATIONAL OBJECTIVE: patients with new communication skills after At the conclusion of this session, the participant practicing exercises teaching techniques that can be should be able to: 1) List the various types of primary incorporated into a clinician’s daily routine. care providers, with their clinical roles and styles; 2) Understand the personnel challenges particular to SUMMARY: safety net primary care clinics with a focus on Implicit bias and microaggressions affect all levels of retention; 3) Appreciate the pressures facing new medical care. Far from being subtle or small, an hire clinicians in primary care settings, which can emerging literature suggests these phenomena can lead to premature burnout or substandard practice; have big effects on access to care, care 4) Outline the role a psychiatrist collaborating with a effectiveness, and even stigma. Manifestations can primary care clinic can play in retention and job range widely, from assumptions about patient satisfaction; and 5) Initiate and guide a fruitful working relationship with a consulting provider as discuss and field ideas about how a working part of a collaborative behavioral health team. relationship can be developed in a way that strengthens the ability of both the behavioral health SUMMARY: team and the primary care providers to achieve their As part of the Gulf Region Health Outreach patient care goals. Program's Mental and Behavioral Capacity Project- Louisiana, psychiatrists and other behavioral health Protecting Youth From Online Dangers: Clinical specialists from the department of psychiatry at Perspectives and Approaches to the Rise of Social Louisiana State University Health Sciences Center Media and Online Risk Taking (LSUHSC) in New Orleans have been collaborating for Chairs: Swathi Krishna, M.D., Caitlin R. Costello, M.D. four years with safety net primary care clinics in both Presenters: Gabrielle L. Shapiro, Paul Elizondo III, urban and rural settings to improve access to mental D.O. health care. A critical challenge to these safety net primary care clinics is clinician retention. The clinics EDUCATIONAL OBJECTIVE: may be located far from population centers or in At the conclusion of this session, the participant undesirable urban areas where it is difficult to should be able to: 1) Recognize the widespread recruit clinical staff. The safety net patient popularity and rapidly expanding domain of online population tends to create a demanding panel for activity precipitously influencing a vulnerable primary care clinicians, exhibiting many underage patient population and impacting their comorbidities such as substance use as well as a mental health; 2) Provide specific data and examples tendency toward advanced illness presentations due regarding the increased online activity of teens and to community stigma or lack of access. New hires examples of the increased risks associated with may be freshly minted family medicine physicians, these activities; 3) Identify and discuss the legality of nurse practitioners, or physician assistants without a online activity by teenagers and underage youth— depth of experience preparatory for the level of when and how does the law protect them and when acuity present. Additionally, as burnout and staff does it not?; 4) Highlight and discuss media reports turnover are common, the new hire may be of psychiatric outcomes of youth affected by their accepting a panel comprised of patients whose online behavior and facilitate discussion on how longitudinal treatment plans and attendant their activity showed “red flags”—examples include expectations for ongoing care began to founder sexting and suicide after cyberbullying; and 5) under treatment by a well-intentioned but Provide clinical considerations and approaches to overwhelmed outgoing clinician. This workshop is identify high-risk online activity within the underage designed as a panel discussion with input from a patient population and how to provide education family medicine physician and a physician assistant about monitoring youth online activity. from an urban and a rural primary care clinic serviced by LSUHSC's collaborative care team; also SUMMARY: present will be a psychiatrist and research associate In recent years, adolescents have become from the team. We will begin with an overview of increasingly invested in social media and online the roles of various primary care providers as well as activities. The rapid adoption of social media outlets the challenges of retention of staff in primary care. such as Facebook, Instagram, Snapchat, and Twitter Next, we will discuss our program with views from by underage users have exposed a vulnerable the psychiatrist consultant as well as the primary population to a variety of legal, personal, social, and care providers themselves, with specific examples mental health consequences. According to recent from our team experiences such as the inheritance research, 92% of teens report daily online activity. of a panel with a preponderance of chronic use Twenty-four percent of these individuals report that opioid and/or benzodiazepine patients. This will they are online "almost constantly," usually using include an overview of how technology plays a role more than one social networking site and sharing in facilitating communication within collaborative copious personal information, including full names, relationships and engendering trust. Finally, we will ages, personal photographs, home addresses, school locations, and social calendars. Communicating and Goldenberg, M.D., M.P.H., Kimberly Gordon, M.D. sharing personal information online exposes adolescents to many risks, including cyberbullying, EDUCATIONAL OBJECTIVE: legal consequences from sexting, exposure to online At the conclusion of this session, the participant predators, and exposing information to unintended should be able to: 1) Define privilege, oppression, audiences, which could impact their plans for the and racism; 2) Develop a self-awareness of our own future. Furthermore, the increase in online activity privilege and/or oppression to better understand and online bullying has become a looming safety how we may impact others; 3) Understand how concern in this population. Negative online exposure racial and power dynamics intersect in complicated can have detrimental effects on the physical and ways and can affect the quality of the psychiatric mental health of teenagers, causing depression, services our agencies provide; 4) Identify anti-racist anxiety, increased suicidal thoughts, and even and anti-oppressive strategies that psychiatrists in reports of completed teen suicide in some cases. leadership roles (e.g., medical directors) can This workshop will highlight the vulnerabilities of this implement into service provision; and 5) Incorporate at-risk population of underage online users and help the above concepts to become allies to diverse identify "warning signs" that may signify that groups of clients and coworkers. patients need intervention and support. Increases in online activity and social media use also have SUMMARY: widespread legal ramifications in the adolescent Oppression is woven into the structure and fabric of population that teens, their families, and providers our society. The evidence is everywhere: murders of may be unaware of. Although adolescents under the black people by police, calls to discriminate against age of 18 are neither recognized in the law as adults religious groups and those with mental disorders, nor understood in psychiatry to have the fully the exploitation of indigenous lands, increasing developed capacity of adults, they easily enter into wealth inequality, and even misogynist and online contracts to be able to use social media. In xenophobic language used by prominent politicians, our workshop, we will highlight the legal protections, not to mention countless mental health-related or lack thereof, of underage online activity. This is an disparities among racial and sexual minority and area of ongoing legal debate and has been the underrepresented groups that suggest these subject of several recent court cases that will be populations have worse prognoses. For every gain highlighted and discussed by our workshop on the side of justice, there is pushback. These presenters. With insufficient legal protection for injustices are not new—they can be considered adolescents posting online, protecting teens from historical traumas, which have accumulated from the risks of immature online decision making often one generation to the next. They impact health, both falls to outside adults. Mental health providers have physical and mental, at the individual and population a unique perspective into activities of their underage levels. They are among the forces that contribute to patients and may be able to provide them with burnout and compassion fatigue among so many in education and warnings about the dangers of online the health professions. In addition to the dramatic activity. Our goal is to provide insight and consequences of these traumas that we see every information that can be used to engage teen day in the media, subtle and perhaps more insidious patients in discussions about protecting themselves forces of racism and oppression are incorporated from the consequences of risky online behavior and into most North American institutions, including our provide information to assist mental health own community mental health organizations. providers on how to approach these sensitive topics Interestingly, minority and underrepresented with their patients and their families. psychiatrists may self-select to work in underserved community clinics and even there find discrimination Psychiatrists as Allies: Navigating Power and from their peers and patients due to the subtle Privilege in Psychiatry microaggressions of an oppressive health system. Chair: Michaela Beder, M.D. Oppression, such as racism, impacts both physicians Presenters: Carissa Cabán-Alemán, M.D., Neal and patients alike. Research shows that there are racial and ethnic disparities in prescribing practices, with current trends, find specific innovative solutions diagnosis, and even adherence to evidence-based already implemented in pockets around the country, guidelines. Many well-meaning providers coming and list actionable recommendations for from a privileged position may have difficulty implementation. recognizing how their comments, recommendations, body language, and policies might be oppressive. Buprenorphine Update and Evolving Standards of This workshop will examine how mental health Care clinicians, including medical directors and leaders in Chair: John A. Renner, M.D. our field, can improve the agencies and institutions Presenters: Petros Levounis, M.D., M.A., Andrew J. we work for by beginning to shed light on our own Saxon, M.D. institutionalized racism and bringing anti-racist, anti- oppressive practices into our agencies and clinical EDUCATIONAL OBJECTIVE: work. This highly interactive workshop will include At the conclusion of this session, the participant audience exercises to define power and privilege, should be able to: 1) Describe treatment protocols explore how these concepts intersect in our daily used by psychiatrists around the country who are work, and provide practical and concrete examples treating opioid use disorder with buprenorphine; 2) of ways in which we, as mental health clinicians, can Discuss cutting-edge research related to use of become allies with those who are oppressed. buprenorphine for treating opioid use disorder; and 3) Describe appropriate patient selection for the Friday, October 20, 2017 newly approved buprenorphine implants for treating opioid use disorder. Addressing the Problem of Access to Psychiatric Services SUMMARY: Chairs: Joseph Parks, M.D., Patrick S. Runnels This workshop is intended for psychiatrists who have a waiver to treat opioid use disorder in an office- EDUCATIONAL OBJECTIVE: based setting. It will augment waiver training At the conclusion of this session, the participant through case presentations and discussion of should be able to: 1) Know the extent of the problem treatment challenges with expert faculty. Topics patients have accessing psychiatric services; 2) addressed will include patient engagement and Understand the impact on quality care and patient monitoring, minimizing diversion, and management satisfaction due to current obstacles impacting of acute and chronic pain. Participants will also be psychiatric services; and 3) Learn recommended encouraged to share their experiences with changes to improve access to psychiatric services. reimbursement policies that impede appropriate treatment. SUMMARY: This report's content includes an environmental Community Resilience and Psychiatry’s Role scan, summary problem statement, Following Disaster recommendations based on research and experience Chair: Glenda L. Wrenn, M.D., M.S.H.P. in the field, and a set of actionable next steps for Presenters: Bowen Chung, M.D., M.S.H.S., Kenneth stakeholders with the capacity to implement these Brooks Wells, M.D., M.P.H., Ben Springgate, M.D., changes in a host of settings such as the Center for M.P.H., Ashley Wennerstrom, M.D., Sheila Savannah Medicaid and Medicare Services (CMS) and SAMHSA; professional trade organizations for EDUCATIONAL OBJECTIVE: psychiatrists, nurse practitioners, physician At the conclusion of this session, the participant assistants, and pharmacists; health care provider should be able to: 1) Identify and improve mental organizations; advocacy organizations; and health disparities in the community; 2) Demonstrate consumer organizations. The report is a practical and apply new skills that will be useful in public document designed to highlight key problem areas, psychiatry settings; 3) Examine how the current distinguish the root causes and effects, identify risks health care system affects patient care; 4) Describe how to transform systems of care; and 5) Recognize set of fairly standard requirements. However, many how to bring new innovations into a variety of journals, including Psychiatric Services and the treatments to improve patient care. Community Mental Health Journal (CMHJ), publish papers with different demands and review criteria. SUMMARY: For example, Psychiatric Services also publishes In the wake of 2005's Hurricane Katrina, Louisiana columns in a wide variety of areas, from financing and, in particular, the New Orleans are have suffered and policy issues to integrated care to research and multiple other devastating natural disasters, which services partnerships. Frontline reports showcase have crippled the region and required massive innovative new programs. Understanding the criteria efforts to rebuild. But despite these traumas, the and how to adapt and present your ideas within communities of New Orleans and the surrounding different formats will increase your success in areas have demonstrated enormous resilience in the publishing. In this workshop, the editor and face of adversity. How have these communities members of the editorial board of Psychiatric bounced back so quickly and what role did Services, and the editor of the CMHJ will present the psychiatrists play in the recovery? This workshop will parameters of the different types of articles focus on Louisiana and New Orleans in the decade published in the respective journals. In Psychiatric following Katrina, including subsequent disasters Services, regular articles and brief reports present that have plagued the region in recent years, the results of original research. In general, regular highlighting the work of recovery and its foundation articles should not exceed 3,000 words, excluding in community-driven change. Participants will abstract, references, and tables and figures. Brief explore how they can contribute to the post-disaster reports should be a maximum 1,800 words well-being of their communities and can work to (excluding abstract, references, and table), plus no strengthen local partnerships necessary to preserve more than 15 references and one table or figure. If the mental health of their communities following a you do not conduct research, other types of large-scale disaster like Hurricane Katrina. submissions may be appropriate. Provocative commentaries of 750 words maximum are invited Creating Your Voice: A Guide to Publishing in for Taking Issue. Authors may also submit Psychiatric Services and the Community Mental commentaries of 1,200 to 1,600 words and no more Health Journal than 15 references for the Open Forum section. Chairs: Lisa Dixon, M.D., Jacqueline M. Feldman, Psychiatric Services columns should not exceed M.D. 2,500 total words, including text, no more than 15 references, and an abstract of no more than 100 EDUCATIONAL OBJECTIVE: words. The CMHJ does not have specific columns, At the conclusion of this session, the participant but often publishes themed issues related to public should be able to: 1) Understand the different types and community psychiatry, and is working to of Psychiatric Services submissions and their enhance submissions from international authors. requirements and understand the types of The workshop will review several examples of the submission sought by the

Mental Health Treatment in Correctional Settings SUMMARY: Chair: Li-Wen G. Lee, M.D. Death rates from drug overdoses have been steadily rising and now represent the number one cause of EDUCATIONAL OBJECTIVE: death in the United States, surpassing motor vehicle At the conclusion of this session, the participant accidents. As a result, there is a national public should be able to: 1) Develop an understanding of health initiative to take efforts to curtail drug deaths historical trends in the incarceration of individuals and prevent drug diversion through the use of with mental illness; 2) Learn about standards of care tougher laws and penalties for improper prescribing in correctional settings and a state model of practices and the implementation of prescription delivering services; and 3) Participate in a discussion drug monitoring programs in virtually every state. about the critical role of psychiatrists, both in These initiatives, designed to safeguard the public correctional settings, and in the care of individuals at health and safety while supporting the legitimate risk of incarceration and/or returning to the use of controlled substances, often result in community from incarceration. psychiatrists interacting more frequently with pharmacies, law enforcement, and regulatory SUMMARY: agencies. This workshop will define some of the risk The statistics are stark. With 2.2 million people held management and liability exposures that in federal and state prisons and county jails, the psychiatrists must recognize when prescribing United States has the largest incarcerated controlled substances, and case examples will be population in the world. Superimposed on this figure used to further illustrate potential liability exposures is data showing that 44 to 75% of inmates, faced by psychiatrists when prescribing controlled depending on correctional setting and gender, suffer substances to their patients. Psychiatrists may face a difficult dilemma when prescribing controlled conflict and manage it is a critical skill. The substances if they learn that the patient is being presenters will describe conditions that lead to prescribed the same medication by another conflict. Participants will have an opportunity to provider, when their patient was not truthful about identify their own approach toward conflict. what medications they are being prescribed or when Interventions to manage conflict will then be it becomes apparent that the patient is misusing the illustrated. Finally, participants will break out into prescribed medication. Psychiatrists often struggle smaller groups to practice managing a conflict with what to do: continue to treat the patient or scenario. terminate with the patient. This session will explore these issues, and risk mitigation strategies will be Sickly Hot: Clinical Consequences of Climate Change presented to help lessen the identified liability and How to Protect Your Patient exposures. Chair: Elizabeth Haase, M.D. Presenters: Robin Cooper, M.D., Elizabeth Haase, Psychiatrists as Leaders: A Guide to Conflict M.D., Janet L. Lewis, M.D., Sander Koyfman, M.D. Management Chairs: Patrick S. Runnels, Serena Yuan Volpp, M.D., EDUCATIONAL OBJECTIVE: M.P.H. At the conclusion of this session, the participant should be able to: 1) Understand how higher EDUCATIONAL OBJECTIVE: ambient temperature changes the course of mental At the conclusion of this session, the participant illness and the effects of psychiatric medications; 2) should be able to: 1) Describe and understand Incorporate new data on the neuropsychiatric structural conditions that cause conflict in the impact of fossil fuel particulates and higher workplace; 2) Describe five style approaches to greenhouse gas concentrations into current conflict; 3) Understand structural interventions to understandings of the etiology of dementia, manage conflict; 4) Apply these concepts to real neurodevelopmental disorders, and other situations in their current work environments; and 5) neurological conditions; 3) Examine the impact of Describe the benefits of broader leadership training recurrent extreme weather events using data from as put forth in public and community psychiatry Hurricanes Sandy and Katrina and contributions from fellowships. the areas of risk prediction, societal determinants of health, multigenerational trauma, and complicated SUMMARY: bereavement; 4) Describe new psychoterratic Over the past several years, the burden to our syndromes such as solastalgia, ecoanxiety, and systems of mental health care is likely to grow, nature deficit disorder; and 5) Discuss possible increasing the demand for capable and innovative clinical interventions using case scenarios and leaders. Consequently, many current practitioners audience dialogue. are likely to be offered leadership opportunities in the coming years, yet clinicians are offered almost SUMMARY: no formal leadership training, and many individuals Climate change is as the greatest threat to global who are promoted to leadership positions struggle health in the 21st century. Rising global temperatures as a result. Public and community fellowships are have caused more frequent natural disasters, among the only training programs in the country accompanied by increases in posttraumatic stress, that offer intensive formal leadership training, but anxiety disorders, depression, and the psychiatric few people have any sense of what that training is consequences of loss, financial distress, and forced like. In this workshop, we will focus on one area of displacement. Fossil fuel particulates that raise leadership to better demonstrate the overall value greenhouse gas production are inducing neuro- of such fellowships. Everyone experiences conflict in inflammation, increasing rates of dementia, stroke, the workplace, especially as health care reform leads and major depression. Heat itself brings unique risks to increased pressures. Whether or not a psychiatrist that are particularly impacting psychiatric patients, is in a named leadership role, being able to analyze increasing aggressive behavior and magnifying the risks of psychiatric medication use and the higher In order to be able to improve the care that we rates of medical morbidities in the chronically provide for our patients, we have to be able to mentally ill. The longer-term chronic impacts of measure it as objectively as possible. Measurement- environmental disruption and habitat loss that are based care (MBC) is one of the keys to improving the occurring are associated with suicide, loss of identity care provided to psychiatric patients. The nature of and dissociation, solastalgia, and other disruptions psychiatric disease and the relative lack of objective to personality and biology that cut broadly across measures lends itself well to the use of patient- and socioeconomic barriers. This didactic workshop will physician-reported measurement-based care. provide participants with an up-to-date review of Various measures can be used help diagnose and the specific mental health impacts of climate triage type of illness and level of severity and change. The first panelist will describe the impact of response to treatment. This workshop will discuss greenhouse gases and fossil fuel particulates on the the use of MBC in psychiatric illness. We will discuss vasculature and brain, focusing on the clinical how measuring the care that you are giving can neuropsychiatric sequelae of this impact. The second improve the care that you give, as well as how MBC panelist will discuss the direct impacts of higher is a core aspect of successful integrated care and temperature on the psychiatric patient: increasing how it can be used to improve physician violence and suicide, increased morbidity and performance on MACRA/quality payment plan mortality from specifically psychiatric medications, measures. The benefits and the challenges of MBC in and factors common in the chronically mentally ill psychiatric settings will be discussed. The use of that contribute to risks of heat stroke and heat MBC in a large psychiatric system at the inpatient, exhaustion. The third panelist will describe the long- residential, and outpatient levels of care will be term impact of extreme weather disasters, using discussed. We will present the design, upkeep, and data from hurricanes Sandy and Katrina. The fourth use of both real-time and retrospective use of this panelist will review psychoterratic syndromes data to improve patient outcomes in various including nature deficit disorder, solastalgia, and psychiatric treatment settings. Case-based ecoanxiety. Each panelist will conclude with a case discussion will follow. example and list of possible interventions, which will be opened up for audience discussion. Violence 201: Advanced Clinical Strategies for Recognizing and Managing Violence Risk Using Measurement-Based Care in Psychiatric Chair: John S. Rozel, M.D., M.S.L. Practice to Improve Patient Outcomes Presenters: Layla Soliman, M.D., Abhishek Jain, M.D. Chair: Jerry L. Halverson, M.D. Presenters: Bradley C. Riemann, Ph.D., Eric A. Storch, EDUCATIONAL OBJECTIVE: Ph.D. At the conclusion of this session, the participant should be able to: 1) Appreciate new evidence EDUCATIONAL OBJECTIVE: delineating which aspects of psychiatric illness are, At the conclusion of this session, the participant and are not, associated with violence risk; 2) Explain should be able to: 1) Understand how real-time the roles of unstructured clinical interviews, outcome measures are being used in a large actuarial instruments, and structured professional psychiatric system to improve care; 2) Choose judgments (SPJ) in various settings; and 3) examples of appropriate acute and longitudinal Understand how threat management and protective outcome measures for various psychiatric disorders; intelligence approaches to clinical scenarios may 3) Understand the appropriate use of broad yield new considerations in mitigating clinical crosscutting measures and more targeted measures; violence risk. and 4) Understand measurement-based care and how it may improve performance on quality SUMMARY: measures. Most people with psychiatric illness are not violent. Most violence is not attributable to psychiatric SUMMARY: illness. People with psychiatric illness are more likely to be victims of violence than perpetrators. While misunderstood by the lay public, psychiatrists know EDUCATIONAL OBJECTIVE: these aphorisms well, and the science that At the conclusion of this session, the participant established them is as robust today as it was 20 should be able to: 1) Demonstrate an understanding years ago, but, fundamentally, these truisms offer of micro, meso, and macro approaches to addressing little in the way of practical guidance about social determinants of health; 2) Gain practical skills recognizing and managing people who are at risk for in a diversity of advocacy approaches; and 3) Discuss violence. This workshop is intended to remedy that challenges in balancing the roles of clinician and need by providing attendees with practical, advocate. memorable, and effective techniques to recognize and manage violence risk derived from recent SUMMARY: developments in the research of violence with We live in challenging times. Economic inequality is particular attention paid to psychotic illnesses, increasing both locally and globally. Governing applying structured clinical judgment tools, and systems are increasingly unstable, with the integrating nonclinical models such as protective entrenchment of deep divisions within populations intelligence and threat management. Psychosis and and the rise of extremist political parties. The social violence risk: The old—and incorrect—wisdom said fabric is fraying as we witness both challenges to to look for command hallucinations and subtypes of democratic institutions and the shadow of delusions. New evidence points clearly to the issues authoritarianism across the world. These of active symptoms in general, comorbid substance international and societal dynamics correlate with use, and medication adherence. Additionally, new health effects, from illnesses related to wars and research reinforces previously recognized trends of refugee crises in the Middle East and Europe to elevated risk to family members over strangers. rising suicide rates in economically marginalized Beyond the actuarial versus clinical debate: areas of the European Union to a general increase in Structured clinical judgment and other hybridized mortality in the United States. There is an urgent tools provide a more flexible framework to guide the need to counter such difficult trends with evidence- identification of highly leveraged risk factors and based arguments for social justice, human rights, targeting of dynamic risk factors for intervention. and health equity. Physicians in general, and Think outside the box: Law enforcement and psychiatrists in particular, are uniquely equipped to protective intelligence intersect with behavioral meet this critical need for advocacy. As physicians science in an emerging field known as threat and mental health professionals, we bring a valuable management. This field has an array of empirically perspective to social justice issues within both derived models for recognizing, managing, and individual clinical encounters and society at large. disrupting intended violence that can be particularly We work with some of the most marginalized people helpful in understanding risk related to psychiatric and see daily the impact that poverty, racism, illness. This workshop will be led by three forensic homelessness, insecure immigration status, and lack psychiatrists, each anchored in different clinical of access to health care can have on well-being. In settings including emergency work, consult-liaison, this workshop, participants will have opportunities and inpatient. They will blend their forensic and to learn about a framework for engaging in advocacy clinical experiences to deliver an engaging and work to improve general health, promote health memorable framework. equity, and increase access to health care. Participants will gain practical skills in several Saturday, October 21, 2017 advocacy methods, which can be used in clinical, local community, and government settings. At the Advocacy Skills for Psychiatrists: From the Clinic to micro level, we will review how psychiatrists can the Capitol impact the social determinants of health (SDH), Chair: Michaela Beder, M.D. including by advocating on behalf of patients for Presenters: Marc Manseau, M.D., M.P.H., Flavio access to care, housing, and social benefits. At the Casoy, M.D., Clement Lee, Esq. meso level, we will explore clinical and community- level programs to address the SDH, and at the macro academia? Does taking a non-accredited fellowship level, we will discuss how research, writing, political make sense? When should I start looking for jobs? Is lobbying, community organizing, and protest actions it like interviewing for residency? What should I be can improve the social and economic conditions that asking about besides salary and hours? Should I affect the mental and physical health of our patients change towns or stay where I trained? Why? and the larger public. In order to have maximum Everyone keeps warning me the entire health care impact, a diversity of tactics is needed to address system is changing. How do I prepare for that? How upstream causes of poor health and to bring about does one set up a private practice? Should I look for social justice. Using case examples from the salaried or self-employed positions? Does anyone do presenters’ experience in Canada and the United psychoanalysis anymore? Can I have an academic States, including from advocacy on poverty and career and still earn a decent living? I want to be a health, immigration detention, gun violence ___. How do I get there? I'm on a J-1 visa. What are prevention, and access to health care, participants my options? These are, of course, not meant to be a will take part in and facilitate an interactive comprehensive list, but are the kinds of questions discussion on opportunities for psychiatrists to take we'd be happy to (help) answer!! on advocacy roles. Doing so is not entirely without risk of professional repercussions, and there will be Motivational Interviewing in Working With Patients opportunity for discussion about balancing With Serious Mental Illness professional and advocacy roles. Chair: Michael Flaum, M.D. Presenters: Brian Hurley, M.D., M.B.A., Florence Beyond the Launching Pad: A Forum for Planning Chanut, M.D. for Life After Residency Chair: Stephen M. Goldfinger, M.D. EDUCATIONAL OBJECTIVE: Presenters: Marshall Forstein, M.D., Ellen Berkowitz, At the conclusion of this session, the participant M.D. should be able to: 1) Describe the core components of the “spirit of MI” and their resonance with the EDUCATIONAL OBJECTIVE: core concepts of mental health recovery; 2) Discuss At the conclusion of this session, the participant the four meta-processes of MI and the potential should be able to: 1) Have a clearer idea of how barriers of each in working with patients with SMI; 3) proceed with their careers after residency; 2) Identify opportunities to apply MI to address and Describe the fellowship application process; and 3) overcome common clinical scenarios characterized Demonstrate the ability to discuss practice and job by ambivalence about change or discord (e.g., options. medication nonadherence); and 4) Begin to apply MI skills in the clinical care of patients with serious SUMMARY: mental illness. The workshop organizers, who among them have decades of experience advising senior residents on SUMMARY: issues of career trajectories, lifestyle choices, and This workshop will discuss the potential advantages post-graduation decisions, are offering this of using motivational interviewing (MI) in working workshop as a "consumer-driven" place to bring with patients with serious mental illness (SMI). Dr. your questions about life after residency. Although Flaum will discuss some fundamental ideas virtually all residency training programs provide underlying the rationale for MI and its resonance as thoughtful and well-designed didactics and clinical a communication style with a recovery-oriented supervision, we have found that residents around versus medical model approach. Dr. Hurley will the country consistently struggle with issues—and introduce workshop participants to the core skills of the lack of information—about what to do after the Four Processes and Recognizing Change Talk and residency is over. The sorts of topics that we hope the relevance of these skills to general psychiatric you will bring for discussion include Is doing a practice in patients with SMI. Dr. Chanut will discuss fellowship essential? How about if I want a career in and demonstrate key reflective listening skills, including the use of open-ended questions, ECHO model to build capacity to address substance affirmations, reflections, summaries (OARS), and use disorders and mental health disorders and the techniques for informing and advising in an MI- benefits for primary care teams and patient care. We consistent manner. Workshop participants will be will also discuss the programs implemented by an asked to practice these skills in guided exercises ECHO "hub" at the Billings Clinic in Montana that using real-world clinical scenarios in working with uses ECHO to expand and enhance treatment for patients with SMI (e.g., around issues of treatment mental health disorders for prisoners. Most recently, adherence). The session will conclude with a the ECHO Institute received funding from HRSA to discussion of how to incorporate these MI skills into support a nationwide program—Opioid Addiction everyday practice. Treatment ECHO—that is offering teleECHO clinics focused on treatment of opioid use disorder, aimed Share Your Wisdom: Using the ECHO Model to at supporting primary care teams in HRSA-funded Mentor PCPs and Expand Access to Care for federally qualified health centers (FQHCs). This Behavioral Health Disorders program is offered out of five separate specialty Chair: Miriam Komaromy, M.D. "hubs" (University of Washington, Billing Clinic in Presenter: Eric R. Arzubi Montana, University of New Mexico, Boston Medical Center, and the Western New York Collaborative) EDUCATIONAL OBJECTIVE: and serves primary care teams from FQHCs from At the conclusion of this session, the participant across the U.S. We will describe our first year of should be able to: 1) Describe the use of the ECHO experience with this program. We will also discuss model to expand access to behavioral health care; 2) the differences between the ECHO model and well- Draft a proposal to use the ECHO model to share known and effective alternatives, such as the their wisdom by mentoring PCPs in behavioral health collaborative care model. Then participants will have care; and 3) Understand the difference between the an opportunity to break into guided small groups to ECHO model and other approaches to expanding draft a plan for how they could develop an ECHO access to behavioral health care. program to serve the needs in their own state or region. Finally, the group will share ideas and SUMMARY: brainstorm about how to use this powerful model Numerous studies have documented the need for effectively. improved access to behavioral health care and the importance of integrated physical and behavioral The Veterans Affairs Mental Health Delivery health care. Nevertheless, these remain elusive goals System: Integrated Clinical Care and Population in our health care systems, in part because of Health Combined scarcity and maldistribution of psychiatrists. The Chair: Harold Kudler, M.D. ECHO model offers an approach to expanding access to care by engaging psychiatrists and other EDUCATIONAL OBJECTIVE: behavioral health providers as expert mentors and At the conclusion of this session, the participant consultants for primary care providers (PCPS) and should be able to: 1) Clarify need for integration of teams, thereby expanding the expertise of the PCPs mental health services across a broad continuum of in addressing patients' behavioral health problems. care settings including Primary Care clinics; 2) Argue ECHO programs use videoconferencing to for the full integration of mental health and simultaneously connect multiple primary care team substance use treatment within a single delivery members (the "spokes") with specialists (the "hub") system and a unified electronic medical record; and and builds capacity via ongoing mentorship and, 3) Define the essential link between clinical and most importantly, case-based learning. The model population health models in reducing Veteran also serves to triage high-complexity and high-need suicide and avoiding fragmentation of care. patients who need referral to psychiatric care. This workshop will discuss the experience that the ECHO SUMMARY: Institute has gained over the past 11 years using the The unique mission of the U.S. Department of Veterans Affairs (VA) has required it to become the of collaborating with service users to transform world's largest, most comprehensive integrated mental health professional education; 2) Plan for system of mental health care and, in addition, one of some of the challenges involved in implementing a the largest population mental health systems. To service user educator model; and 3) Outline an achieve the needed scope, continuity and quality of opportunity for collaborating with service user care, VA has overcome unnatural divisions in mental educators in their local context. health delivery which, none-the-less, persist across most other systems. These include (but are not SUMMARY: limited to) the interfaces between: delivery of Calls for the transformation of mental health and services by psychiatric, psychological, social work addiction systems to better support recovery and other disciplines; inpatient, outpatient and emphasize the need for mental health professionals residential mental health care; mental health and to support choice, instill hope, and foster self- substance use services; mental health and primary determination and empowerment. The changes care, and; VA and community care. The modern VA required of the mental health professional system grew out of the experience and advocacy of workforce to enable these improvements are as yet World War I military psychiatrists who realized that poorly characterized but are likely to be substantial. no other organization had the mission, the scope of One promising educational innovation that is gaining skills or the resources necessary to meet the mental ground is the service user educator model, wherein health needs of Veterans. A full century later, VA service users (i.e., people with lived experience of continues to pursue this mission through the mental health and/or substance use challenges) are delivery of clinical care, research and teaching. VA positioned not in their traditional roles of objects of also plays a key role in response to national study but as active collaborators in education at all emergencies and to major public health issues levels, including formal instruction, curriculum including the current epidemic of suicide among design, assessment, and educational oversight. Veterans, military service members and all Proponents of this model argue that service user Americans. Of special significance, VA's mission has educators are uniquely positioned to convey the always incorporated a population health approach to lived experience of recovery and facilitate a critical mental health; a perspective to which the nation is analysis of services and that their involvement only just awakening. This workshop will explore VA's represents a powerful opportunity to combat history, policy and current operations and provide prejudice at early and critical stages of professional ample time for give and take among participants in training. The presenters will review the service user order to clarify why every clinician in the nation educator literature with a focus on co-production as needs to have basic military cultural competence a conceptual framework for collaboration. Next, they and a practical working knowledge of the VA mental will describe their experiences and evaluation data health system. from collaborations with service user educators for diverse groups of learners (psychiatry residents, Sunday, October 22, 2017 fellows, and frontline clinicians) at three academic centers (Columbia, Yale, and Toronto). Opportunities Collaborating With Service Users to Transform for making a powerful system impact as well as Mental Health Professional Education: Going implementation challenges will be highlighted. Last, Upstream to Redefine Effective Care participants will be guided in drafting a plan for Chair: Sacha Agrawal, M.D., M.Sc. increasing the level of involvement of service user Presenters: Stephanie Le Melle, M.D., M.S., Rebecca educators at their own institutions. Miller, Ph.D., Serena Spruill, Michaela Beder, M.D., Kim McCullough, B.S.W. Improving Public Health Impact Through Mental Health Services Research: Funding Priorities and EDUCATIONAL OBJECTIVE: Tips From the National Institute of Mental Health At the conclusion of this session, the participant Chair: Michael C. Freed, Ph.D. should be able to: 1) Describe the potential impact Presenters: Susan T. Azrin, Ph.D., Denise Juliano-Bult, Denise Pintello part of a continuously improving health care system that is crucial to improving the nation's public EDUCATIONAL OBJECTIVE: health. Here, the translation of findings is At the conclusion of this session, the participant bidirectional. Service system leaders, providers, should be able to: 1) Discuss high funding priority health care beneficiaries, and other key stakeholders areas for NIMH services research; 2) Present an drive research questions so that seminal research overview of the NIMH’s experimental therapeutics findings will dramatically influence practice change. paradigm that is required for all services research In this workshop, NIMH program officials will discuss involving clinical trials; and 3) Field questions related high funding priority areas for mental health services to funding priorities, available funding mechanisms, research to include the following: suicide and submission of meritorious applications. prevention, autism spectrum disorder services, reducing the duration of untreated psychosis, SUMMARY: integration of mental health into primary care and As the largest funder of mental health services other nontraditional settings, leveraging technology, research in the United States, the National Institute dissemination and implementation science, research of Mental Health (NIMH) is committed to supporting involving children, systems of care, new methods, meritorious services research. The constantly financing, disparities, and research networks. In changing health care landscape creates new addition, they will present an overview of the challenges to the delivery of high-quality treatments experimental therapeutics paradigm, which is and services to children, youth, adults, and older required for all services research involving clinical adults with unmet or undermet mental health trials. Finally, program officials will field questions needs. Epidemiological findings suggest that related to funding priorities, grant mechanisms, and approximately one half of the U.S. population meets other relevant topics to encourage potential lifetime criteria for a mental disorder, and applicants to submit competitive applications. approximately one quarter of the population meets criteria in any given year. However, only one half of Prescribing Clozapine: The Nuts and Bolts of people with any mental health disorder and only two Successfully Using an Underutilized Medication thirds of people with a serious mental health Chair: Robert Osterman Cotes, M.D. disorder received mental health services in the Presenter: Anthony Battista, M.D., M.P.H. previous year. Of those who find their way into mental health care, many fall out of care and/or do EDUCATIONAL OBJECTIVE: not receive guideline-concordant treatment. At the conclusion of this session, the participant Disparities in population status, a fragmented health should be able to: 1) Identify appropriate indications care system, provider shortages, health care and candidates for clozapine use; 2) Understand how affordability, and other factors moderate the to start clozapine, including dosing and strategies to likelihood of accessing and remaining engaged in manage and mitigate common and life-threatening high-value mental health services. Transformative side effects of clozapine; and 3) Develop strategies mental health services research is needed to to improve clozapine utilization in one’s own improve access, continuity, quality, equity, practice setting. efficiency, and value of mental health services; to bring effective strategies and practices to scale; to SUMMARY: sustain them; and to ultimately maximize public Clozapine remains one of the most effective health impact. The NIMH seeks innovative research pharmacological tools in treatment of persistent that will inform and support the delivery of symptoms of psychosis. Although it is estimated that consistently high-quality mental health services to up to 20-30% of individuals with a diagnosis of benefit the greatest number of individuals with, or at schizophrenia could potentially benefit from risk for developing, a mental illness. The pathway of clozapine, only five percent are actually prescribed evidence can be thought of as discovery to delivery, this medication. Administrative burden, lack of but the NIMH also sees discovery out of delivery as coordinated laboratory or specialist services, and both consumer and prescriber concerns are have contributed to a growing crisis in pediatric commonly cited causes of underutilization. Through mental heath care, with an estimated four in five an interactive discussion using several case youth with mental health problems unable to vignettes, this workshop will provide the prescriber receive the care they need. Integrated care models practical information to use clozapine with greater seek to address these barriers by improving pediatric confidence. Highlights will include discussion on the access to behavioral health care services through indications, efficacy, side effect profile, titration delivering and coordinating care via strategies, drug-drug interactions, use of the REMS psychoeducation and consultation to primary care system, and strategies for adjunctive treatment to providers. Pediatric integrated care models have clozapine. Finally, in a small group format, attendees been shown in randomized clinical trials to be will develop strategies to optimize and increase feasible and cost effective and, most importantly, to clozapine utilization in their own system of care. lead to superior health care outcomes compared to usual care. They also lead to reduced mental health Specialty Care in Integrated Care: Providing stigma as youth and families are more willing to seek Integrated Care for Pediatric Mental Health mental health care delivered in their medical homes Chair: Robert Hilt, M.D. from their primary care providers who, by having Presenters: William P. French, M.D., Cecilia P. ongoing consultation with mental health specialists, Margret, M.D., Ph.D., M.P.H., Erin Dillon-Naftolin, are able to gain confidence and improve their M.D. knowledge and skills in delivering mental health services. While the demand for integrated care is EDUCATIONAL OBJECTIVE: growing, training for psychiatrists in how to provide At the conclusion of this session, the participant this care is lagging behind, particularly for youth. should be able to: 1) Describe models of integrated Through the new state-funded University of care for pediatric mental health (PMH); 2) Discuss Washington Integrated Care Training Program, we curriculum development for child mental health have developed a curriculum for teaching core topics relevant for integrative care and describe components of child and adolescent psychiatry to education strategies to engage adult learners based adult psychiatrists who plan to work in integrated upon adult learning theory; 3) Demonstrate care settings and may be asked to provide support to improved consultant expertise for common pediatric pediatricians and family medicine providers. The first mental health disorders and topics; 4) Describe part of the workshop will be an overview of the core challenges and important implementation principles and team structure of integrated care in considerations for PMH integrated care; and 5) pediatric mental health. The following section will Develop an individualized plan for enhancing review the 3 main variants of integrated care models integrated care support for pediatric providers currently in development: 1) coordination; 2) depending on type of clinical setting most relevant colocation; and 3) collaborative care. The third for the participant’s current or planned practice. section will focus on curriculum development and learning strategies for adult learners for a selected SUMMARY: sample of pediatric mental health disorders and Over the last 20 years, models of integrated care— related topics. Following this, we will break out into defined as care provided by a team of health small groups based upon the disorders and topics professionals working together to coordinate and discussed in the third section, from which attendees deliver behavioral health services in primary care may choose to learn topics relevant to their practice. settings—have been demonstrated to improve We will then regroup to review the implementation health care outcomes in adult populations. More strategies and challenges involved in setting up recently, there is a growing movement to implement integrated pediatric mental health consultation integrated models in pediatric populations due to practices. Last, attendees, along with a facilitator, clear evidence that specialty care workforce will again break into smaller groups to design shortages, ongoing mental health stigma, lack of individualized integrated care models. care coordination, and other systemic problems socioeconomically deprived neighborhoods. Teaching Medical Students About Psychiatry: Students have opportunities for additional exposure Planting the Seeds for Integrated Care to psychiatry not only with a traditional psychiatry Chairs: Ann Hackman, M.D., Constance Lacap, D.O. interest group but also with an intensive elective Presenters: Vedrana Hodzic, M.D., Marissa Flaherty, course, the Combined Accelerated Psychiatry M.D., Curtis Adams, M.D., Benjamin Ehrenreich, Program, a specialized longitudinal program of 50 M.D., Jamie Spitzer, M.D. years' duration designed for interested students. The second-year psychiatry didactics focus on increasing EDUCATIONAL OBJECTIVE: awareness and reducing stigma, as well as teaching At the conclusion of this session, the participant the basics. Students participate in an exercise in should be able to: 1) Identify some of the challenges simulated auditory hallucinations and hear stories of to teaching psychiatry to medical students; 2) personal experience and recovery from people living Recognize at least three novel ways to introduce with the diagnoses students have learned about in students to psychiatry; and 3) Implement techniques the lecture halls. Each second-year medical student to reduce stigma around psychiatric illness and does an individual interview of a person currently treatment and prepare medical students to work in receiving psychiatric treatment with our division of integrated care settings. community psychiatry. Broad exposure to inpatient, outpatient, and emergency psychiatry, as well as SUMMARY: elective experiences with ACT and private practice, Integrated somatic and psychiatric care is a model continue into the clerkship and clinical years. At each that optimizes access to psychiatric care for those step in this process, educators from the department who need it. To create and sustain an integrated of psychiatry assess student feedback and focus on system and facilitate access to psychiatric care, it is the importance of a good understanding and respect essential to begin with medical student training. for people with psychiatric diagnoses and symptoms Most medical students begin with little knowledge of in all areas of medical practice. This workshop will psychiatry and a perspective fraught with consider relevant literature, describe and explain stigmatizing attitudes held by many and perpetuated approaches in our program, and, with our audience, by entertainment and media. Additionally, students consider these and other strategies for preparing have limited understanding of the relevance of young physicians to practice fully integrated care psychiatry to other fields of medicine. To facilitate and thus expand access to care. the development of young physicians committed to integrated care, training should focus on creating Treating Survivors of Intimate Partner Violence early, positive experiences with psychiatry faculty (IPV): Improving Access to Care With an Integrated and residents, on addressing and reducing stigma Service Model around psychiatry and psychiatric diagnoses, on Chair: Mayumi Okuda, M.D. facilitating education about psychiatry in a Presenters: Elizabeth M. Fitelson, M.D., Obianuju nonjudgmental environment and on exposing "Uju" J. Berry, M.D., M.P.H., Rosa Regincos, L.C.S.W. students to the broad world of psychiatric treatment. At the University of Maryland School of EDUCATIONAL OBJECTIVE: Medicine, an urban training site in Baltimore At the conclusion of this session, the participant providing treatment for many impoverished and should be able to: 1) Describe the common barriers underserved individuals, we have undertaken some to mental health care for intimate partner violence innovative approaches to medical student training in (IPV) survivors and the rationale for trauma- psychiatry. Exposure to psychiatrists often begins informed services for this population; 2) Summarize prior to acceptance, with many faculty members clinical, legal, and training recommendations that serving as interviewers and on the admissions can improve access to care for IPV survivors; and 3) committee. One member of the psychiatric faculty Discuss the benefits of a multi-specialty collaborative introduces the incoming class to the city of model that effectively treats IPV survivors’ multiple Baltimore with a bus tour including needs. survivors in a wide range of settings. At the SUMMARY: conclusion of the workshop, the participant will be Intimate partner violence (IPV) is a major public able to discuss practical strategies that can improve health problem that results in a wide range of short- access to care, as well as learn about a model that and long-term adverse mental health consequences. provides integrated services to IPV survivors and In the general population, approximately 20% of other non-combat trauma survivors. individuals who experience IPV within a year develop a new psychiatric disorder. IPV survivors compared to those free of IPV are four times more likely to attempt suicide at some time in their lives. In selected samples such as domestic violence shelters, the prevalence of PTSD and MDD has been reported to be as high as 84% and 61%, respectively. Despite the elevated rates of co-occurrence of IPV and mental health problems, there is significant evidence that the mental health needs of IPV survivors continue to be unmet and that these problems are heightened among minority groups. IPV survivors often feel misunderstood, unsupported, and even blamed when they interact with the mental health care system. Such negative experiences can perpetuate a damaging cycle of revictimization and mistrust. Furthermore, in spite of the well- recognized urgency to increase mental health resources for trauma survivors in the U.S., most mental health professionals do not receive formal education and training in trauma-related mental health. Trauma and IPV are not routinely included in the professional training of most psychiatry and psychology programs in the United States. The presentation will describe common challenges in working with this population including safety issues, revictimization, and providers' challenges, including lack of competency in trauma treatments and vicarious trauma. This presentation will illustrate lessons learned throughout the development and expansion of a program that integrates mental health services with community-based ones for IPV survivors, as well as describe the development of a training and supervision model for mental health clinicians caring for IPV survivors in these settings. The presentation will also provide a platform for discussion on ways to increase awareness of and training on IPV/non-combat trauma and how to enhance the national capacity to provide mental health services for this population. This workshop will be presented by a team of professionals in the fields of advocacy, social work, psychology, and psychiatry who have experience working with IPV